Health Insurance for People with COPD

COPD and ACA Coverage Protections

COPD is a pre-existing condition that, before the ACA, could result in coverage denial or exclusion of respiratory care. Under the ACA, insurers cannot deny coverage or charge higher premiums due to COPD or any other pre-existing condition. All ACA marketplace plans cover COPD-related care as medically necessary treatment.

What COPD Patients Need From a Health Plan

• Pulmonologist in-network: COPD is typically managed by a pulmonologist in addition to a primary care physician. Verify your pulmonologist is in-network before enrolling.
• Inhalers and bronchodilators: COPD medications include LABAs, LAMAs, ICS combinations (Spiriva, Advair, Symbicort, Trelegy, Breo Ellipta). These are branded medications that can be expensive — check formulary tier and prior authorization requirements.
• Pulmonary rehabilitation: ACA plans must cover pulmonary rehabilitation as a rehabilitative service (an essential health benefit). Confirm coverage with your plan.
• Hospitalizations: COPD exacerbations often require hospitalization. The hospital where your pulmonologist has privileges should be in-network.
• Home oxygen: If prescribed, home oxygen is covered as durable medical equipment. Prior authorization is typically required.
• Out-of-pocket maximum: COPD is a condition with real hospitalization risk. Choose a plan with an OOP maximum you can pay if needed.

Choosing the Right Metal Tier for COPD

COPD typically involves ongoing medication costs and at least periodic specialist care. For most COPD patients, a Silver or Gold plan provides better total value than a Bronze plan when you factor in lower cost-sharing on medications and specialist visits. The higher Bronze deductible can be prohibitive if a COPD exacerbation requires an ER visit or hospitalization.