Does this time of year stress you out? Not because of the holiday shopping, but because you have to choose the right health insurance. According to a 2025 study published by CDC, roughly 76.4% of U.S. adults reported having at least one chronic condition in 2023. Research also found sex disparities shows that women bear a heavier burdenfor certain chronic illnesses. For example, women account for nearly 80% of autoimmune disease cases in the U.S.
As the next open enrollment window deadline approaches on December 15, millions are scrambling to pick health insurance plans that fit their specific needs.
For women managing chronic illnesses, choosing the right plan is the difference between manageable care and medical chaos. Although there’s no “right” plan, there are “best” plans that can make dealing with chronic illnesses tolerable.
Choosing Smart Coverage
Instead of choosing a plan solely on the lowest monthly cost, model your worst-case medical spending for the year, including medications, specialist visits, diagnostics and possible hospitalizations. Then, compare that against each plan’s coverage structure. Only then can you assess which tier actually makes financial sense.
Health insurance tiers typically have an inverse relationship between the deductible and premium amounts. Bronze-tier plans usually have the highest deductibles and the lowest premiums, while Platinum-tier plans have the lowest deductibles but the highest premiums.
Kavya Ravikanti, senior product manager, consumer at Turquoise Health, states, “If you know you’ll likely meet your deductible due to ongoing medical costs, you’ll likely want to choose between gold and platinum plans to see where your out-of-pocket costs will be the lowest. Once you meet your deductible, these tiers will cover the majority of your healthcare costs when you need care.”
She adds that a silver plan can make more sense for some women. “If you qualify for silver tier cost-sharing reductions, in the form of premium tax subsidies, the silver tier may be a better option for you than gold.”
Those structural choices are only one part of the work. Once you understand the tiers, the next step is getting specific about how your actual care fits into the fine print. This is where many women with chronic conditions face challenges because plans that look similar on the surface can behave very differently once you factor in medications, specialists and cost-sharing rules.
Ravikanti breaks down the key areas to examine before you enroll:
- Formularies. “Look at how your prescriptions will be covered within the formulary. What tier do your prescriptions fall into? Specialty drugs typically fall into higher tiers, which will mean higher costs. Depending on your prescriptions, you may save on your overall out-of-pocket costs by picking a plan with higher premiums that covers your prescriptions within a lower tier.”
- Networks. “Check to see if your providers will be considered in-network or out-of-network. If your specialist is out-of-network, you may face higher out-of-network costs for your visits. Look up how providers you may need in the future will be covered by the plan design.”
- Cost-sharing structures. “A lower deductible plan may have lower out-of-pocket costs in the long run, even if you’ll have to pay a higher premium if you’re in need of frequent care while managing your chronic condition. Look for plans with co-pays for specialists or prescriptions for predictable costs while you’re making progress towards your deductible.”
An HSA and an FSA should also be considered. An HSA is tied to a high-deductible health plan and gives you long-term flexibility. The money you contribute is yours to keep year after year; it can be invested, and it travels with you if you change jobs or insurance.
An FSA is far more rigid. The funds usually follow a “use it or lose it” rule within the plan year, and the account stays with your employer, not you. FSA is a short-term budgeting tool meant to cover predictable annual expenses, such as co-pays, prescriptions or therapy visits.
Women with chronic conditions tend to get more freedom from HSAs.
What Medical Professionals Recommend
“People with chronic conditions feel most blindsided when their health plan’s preferred drug list changes, especially when it happens mid-year,” states Dr. Colin Banas, M.D., chief medical officer at DrFirst. “Changes in prior authorization requirements run a close second.”
He recommends people reach out to their primary care doctors or specialists, asking these three critical questions:
- Ask if the medication is on your plan’s formulary for next year and whether it’s been moved to a higher or lower tier. For example, a drug moving from tier 2 to tier 4 can mean thousands of dollars in added costs.
- Ask what the prior authorization requirements will be. Even if you are already taking the medication, your insurer may require a new prior authorization. Knowing ahead of time means you and your doctor can plan for it.
- If there will be a new prior authorization, ask if your plan requires step therapy, which means you may have to try and fail on less costly drugs before your plan approves the medication that’s already working for you.
Nearly all physicians have reported that prior authorization delays impact patient care, according to a survey by the American Medical Association.
Banas explains how patients can plan ahead:
- Use a calendar or reminder app to flag refill dates a month in advance. That gives you time to fix any issues.
- If your medication comes through a specialty pharmacy, get to know that team. They’re often the first to hear about formulary changes and can connect you with pharmaceutical company programs that may help.
- Ask your doctor to document medical necessity for your medication in your chart during a healthcare visit. This speeds prior authorization approvals because the documentation is readily available, rather than requiring a time-consuming retrospective chart review.
Additionally, check the websites of pharmaceutical companies for copay assistance cards. Some offer patient support programs for people who meet income requirements, while others are available regardless of insurance status.
A Patient’s Perspective
For many women, open enrollment means confronting hard choices like skimping on monthly costs and risking huge bills later, or paying more upfront for a sense of security.
Nicoletta Sozansky, BCPA, founded Healthcare Redefined after navigating the healthcare system for years after being diagnosed with mast cell activation syndrome.
“For me, the most important factor is whether the plan is accepted by my principal specialists handling my chronic conditions, the ones I rely on and am not ready to part with,” she explains. “Because finding new doctors with similar skills and expertise could take a very long time, provider participation always becomes the largest driver of my decision, even if it means higher monthly premiums.”
Sozansky’s focus on keeping long-term specialists is common among women managing chronic illness, but confirming whether those providers actually take the plan you’re considering is its own hurdle. That’s because participation information isn’t always accurate.
It’s important to verify participation directly with the provider before plan selection, rather than relying on insurer directories or even doctor or hospital websites. These listings are often outdated for both Marketplace and Medicare plans.
Sozansky continues, “Given my chronic conditions and often unpredictable needs, I personally choose plans with low deductibles and higher monthly premiums. Having an idea of my estimated monthly spend on doctors and hospitals, capped by monthly premiums and a predictable co-insurance, helps with financial planning and estimates of my medical care costs.”
General Assistance Foundations
Beyond picking the right insurance plan, there are also foundations and grants that help qualified patients cover some of their medical costs:
- HealthWell Foundation: Provides grants to underinsured patients with chronic or life-altering diseases to help cover out-of-pocket costs such as co-pays, premiums, and deductibles.
- Patient Access Network Foundation: Offers disease-specific funds to help underinsured patients.
- Patient Advocate Foundation: Provides grants on a first-come, first-served basis to patients who meet specific financial and medical criteria.
- The Assistance Fund: Helps insured individuals afford medications, premiums and other medical-related expenses.