Health Insurance

Access to health insurance may pose a challenge for people with lupus. This section provides information on the different insurance options that may be available to you.

Health Insurance Options

Health insurance is a contract between you and your insurance company. When you purchase insurance, the company agrees to pay part of your medical costs when you get sick or hurt. There are a number of health insurance options and a new option available beginning October 1, 2013 is the Health Insurance Marketplace.
Know the following to determine your options for health insurance coverage:

Your age
Your state of residence
If you can obtain insurance through your job
If you can obtain insurance through your spouse, legal guardian or school
If you are a US citizen
Your income compared with the federal poverty level (FPL)
If you have served or are serving in the US military
If you are pregnant
If you have a disability

In addition, if you are a person with lupus, ask the following about insurance coverage:
Are the medications I take on the plan formulary?
Are the specialists and facilities I visit regularly in the plan's network?
What are my out-of-pocket costs to go out of the plan's network?

Five things I need to know about health insurance (pdf)


If you make less than a certain amount of money each year or are disabled, you may be able to receive Medicaid. For more information visit

Children's Health Insurance Program (CHIP)

CHIP offers health insurance for children. You may be able to receive CHIP if you work but cannot obtain insurance through your job or your income is too much to qualify for Medicaid. For more information visit:
Washington DC


Medicare offers health insurance for people who are 65 years or older.  People who have been disabled for more than two years may be able to receive Medicare. For more information visit

Employer-Sponsored Insurance (ESI)

ESI may be offered through your job.  Some types of ESI include:
HMO: Health Maintenance Organizations -uses a network of doctors; requires a primary care physician.
PPO: Preferred Provider Organizations- uses a network of doctors; if you go out-of- network, it will cost more.
POS: Point of Service- uses a network of doctors; does not require referrals to specialists; if you go out-of-network, it will cost more.
Every company’s health insurance is a little bit different. Talk to your company’s human resources or benefits person for details.

Private Insurance

There are numerous private insurers offering a variety of options for health insurance coverage to include Health Maintenace Organizations (HMO), Preferred Provider Organizations (PPO) and Point of Service (POS).  Contact each private insurer directly for more information on their specific plan options.

Health Insurance Marketplace

Beginning October 1, 2013, a new option for obtaining health insurance will be available.  The Marketplace is a way to learn about different insurance plans, compare plans and find out which one fits your needs.  If you do not qualify for other types of insurance, the Marketplace will offer options for purchasing health insurance.  Visit for more information.
Washington DC

Health Reform and You: A User's Guide to Health Insurance Marketplaces
Eight things I need to know about the Health Insurance Marketplace (pdf)
Things to think about when choosing a health insurance plan (pdf)
Glossary of health coverage and medical terms (pdf)
What happens if I do not have heath insurance coverage in 2014