How Chronic Illness Patients Save Money by Understanding Insurance

Part 1 | Understanding Insurance and How to Fight for Every Dollar

 

For people managing chronic illnesses, the real cost of care is often hidden in paperwork. Coverage shifts, coding errors, prior authorizations, and tier changes can turn predictable treatment into financial shock. Across the country, patients are proving that savings come not from luck, but from literacy. They come from knowing what to question, when to appeal, and how to use nonprofit support to correct system errors.

 

 

When Patients Push Back and Win

 

Insurance denials are rarely final. Analyses from KFF Health News show that many ACA Marketplace denials change outcomes when patients submit clear medical-necessity documentation and follow the formal appeal pathway.

 

A CMS-reviewed case example describes a patient with multiple sclerosis whose insurer initially denied an infusion because of a coding mismatch. After the patient submitted supporting chart notes along with the plan’s own medical-policy language, the denial was overturned and the claim was reprocessed at the correct rate. This pattern appears throughout Patient Advocate Foundation data as well. The organization reports frequent reversals when documentation fills the gaps that triggered the denial in the first place.

 

Appeals tend to succeed when:

• documentation is specific 

• medical records clearly show necessity 

• policy language is quoted verbatim 

• the patient maintains a complete paper trail

 

 

When Coverage Hides in the Fine Print

 

Chronic-illness supplies and devices often fall into more than one benefit category. They may be billed as pharmacy, medical, or Durable Medical Equipment (DME). The category determines the cost.

 

The American Diabetes Association (ADA) has documented cases in which people with diabetes save significantly by billing continuous glucose monitors under DME rather than pharmacy when their plan allows it. In one ADA-profiled example, a Texas parent managing a child’s Type 1 diabetes had CGM sensors denied under pharmacy benefits. After requesting a benefit cross-check with the insurer, the claim was approved under DME with a far lower copay. The plan did not change. Only the billing route did.

 

Sally had the same realization in early 2024. Her rising pharmacy charges seemed random until she read each line of her plan’s coverage categories and discovered that multiple medications had been re-tiered during a formulary update she never saw.

 

“When I finally matched my meds to my benefits, the numbers stopped surprising me,” she said. “Half my stress came from not knowing how the plan actually worked.”
— Sally Figueroa

 

 

Choosing the Right Plan Can Pay You Back

 

For many people with chronic conditions, Cost-Sharing Reductions (CSRs) on Marketplace silver plans lower deductibles, out-of-pocket maximums, and specialist copays.

 

According to CMS Marketplace analysis, eligible enrollees who move from bronze to silver plans typically see substantial reductions in real annual spending — even when premiums increase slightly — because specialist visits, labs, and chronic-care follow-ups fall under lower CSR cost-sharing. This pattern reflects what many chronic-condition enrollees experience: slightly higher premiums but drastically lower point-of-care costs.

 

 

Appeals Are Corrections, Not Confrontations

 

The Patient Advocate Foundation (PAF) reports average annual savings of more than $4,000 per client through appeals, bill corrections, and charity-care enrollment. Their data show that most denials stem from clerical errors, missing documentation, or coding mismatches rather than intentional refusals.

PAF leadership often describes appeals as “corrections.” This reframing helps patients view the process as a fix, not a fight.

 

 

Five Steps with the Highest Return

 

1. Read your plan like a contract.

Download the Summary of Benefits and Coverage. Highlight your deductible, out-of-pocket maximum, DME coverage, specialty tiers, and prior-authorization rules.

 

2. Check both medical and pharmacy benefits.

Ask your provider, “Can this be billed under DME instead of pharmacy?”
The ADA emphasizes this step for diabetes supplies and CGMs.

 

3. Appeal denials in writing every time.

Under the Affordable Care Act, all plans must provide internal review and external review. 

 

4. Use nonprofits early, not after a crisis.

Patient Advocate Foundation
Patients Rising Helpline
These groups assist directly with appeals, denials, and bill corrections.

 

5. Document everything.

PAF datasets show that patients who keep detailed documentation, including EOBs, call logs, and case numbers, are twice as likely to win their appeals.

 

 

The Bigger Picture

Across the stories referenced here, the pattern is the same. A denial was reversed. A CGM billed correctly. A CSR plan selected intentionally. A formulary shift uncovered. Each example shows that the path toward affordable care runs directly through the paperwork.

 

 

Our Pay It Forward Approach

Every small act of sharing creates a ripple. If this piece resonated with you, consider sending it to someone who might need the same hope today—or leave us a comment in the section below with your own saving story so thousands can benefit from it. No one should have to navigate the cost of illness alone.

 

 

Verification Note

All sources verified December, 2025
All sources are government, nonprofit, or primary reporting organizations.

Insurance Denials, Appeals & Reversals

KFF Health News — How Insurance Appeals Work and Why They Succeed
https://kffhealthnews.org/news/article/health-insurance-appeals-denials-how-to-fight-back/

KFF Health News — Marketplace Denials and Patient Appeals
https://kffhealthnews.org/news/article/obamacare-marketplace-denials-appeals-consumers/

Centers for Medicare & Medicaid Services — Internal and External Review Rights
https://www.cms.gov/cciio/resources/fact-sheets-and-faqs/appeals

Affordable Care Act Appeal Protections

HealthCare.gov — How to Appeal an Insurance Denial
https://www.healthcare.gov/appeal-insurance-company-decision/appeals/

U.S. Department of Labor (EBSA) — Claim Denials and Appeals Process
https://www.dol.gov/agencies/ebsa/about-ebsa/our-activities/resource-center/publications/claims-procedure

Coding Errors, Medical Necessity & Documentation

CMS — Medical Necessity and Claims Processing Errors
https://www.cms.gov/medicare/appeals-and-grievances/mln/appeals

National Association of Insurance Commissioners — Health Claim Denials Explained
https://content.naic.org/consumer/health-insurance-claims-denials.htm

Durable Medical Equipment (DME) vs Pharmacy Billing

American Diabetes Association — Insurance Coverage for CGMs and Diabetes Technology
https://diabetes.org/tools-support/insurance/health-insurance-and-diabetes

ADA — Medicare and Private Insurance Coverage of CGMs (DME Classification)
https://diabetes.org/diabetes/medication-management/continuous-glucose-monitoring

Marketplace Plans & Cost-Sharing Reductions (CSRs)

CMS — Cost-Sharing Reductions Overview
https://www.cms.gov/marketplace/private-health-insurance/cost-sharing-reductions

HealthCare.gov — Silver Plans and Cost-Sharing Reductions
https://www.healthcare.gov/glossary/cost-sharing-reduction/

CMS — Marketplace Plan Metal Levels and Consumer Costs
https://www.cms.gov/marketplace/resources/data/metal-levels

Nonprofit Patient Advocacy & Savings Outcomes

Patient Advocate Foundation — 2023 Impact Report (Appeals & Bill Corrections)
https://www.patientadvocate.org/connect-with-services/impact-report/

Patient Advocate Foundation — Insurance Appeals and Case Management
https://www.patientadvocate.org/connect-with-services/case-management-services/

Patient Support & Helplines

Patients Rising — Helpline and Insurance Navigation Support
https://patientsrising.org/helpline/

Patients Rising — Coverage, Appeals, and Access Resources
https://patientsrising.org/resources/insurance-and-access/