As the end of 2016 approaches, there are certain questions you need to ask yourself about your health insurance. Regardless of how you and your family obtain your health insurance, it is ultimately your responsibility to understand your plan. It is up to you to choose the plan that is right for you and your family's healthcare needs.
Understanding your plan can have a huge impact on both your health and your finances.
What should I consider during open enrollment when my employer is offering new plans?
Individuals affected by primary immunodeficiency diseases (PI) need to make educated decisions about their coverage options. Do a thorough plan comparison to determine what plan best fits your needs. Things to look at include:
- What is my premium?
- What is my out-of-pocket maximum?
- What are my deductibles?
- Is deductible included in the out-of-pocket maximum or is it in addition to the maximum?
- How is immunoglobulin (Ig) covered?
- Do I have a coinsurance or a flat co-pay?
- Do I have options for the site of care?
- Are my doctors in the plan's network?
- Are there out-of-network benefits?
You may need to contact the insurance carrier or get assistance from your benefits or human resources department in obtaining the answers to these questions. Once you have these questions answered, you can make an informed choice.
What do I do if I've met my annual deductible for 2016?
If you have met your annual deductible for 2016, this is a time to consider scheduling any medical treatments you still need. When a new calendar year begins, out-of-pocket limits and deductibles reset. This may be a good time to consider what treatments or services you could schedule before the end of the year that would be covered under your plan. If you have questions about determining if you've met your deductible. contact your insurance carrier, or, if you get health insurance through your employer, talk with your benefits of human resources department for assistance.
What if I'm eligible for Medicare?
Similar to choosing a plan from your employer, you need to do a thorough evaluation of the choices to determine the plan that works best for you. There are many options when it comes to Medicare coverage. Ask yourself the same questions as noted previously when you choose a plan.
If you receive Ig therapy, check out how your treatment will be covered. Ig therapy, whether intravenous (IVIG) or subcutaneous (SCIG), will be covered under the traditional Medicare Part B medical benefit. This is only covered at 80%, requiring patients to obtain a supplemental/medigap plan to cover the remaining amount. Another option is a Medicare Advantage plan (Part C). These plans are sold as an "all in one policy" and act more like a private insurance. According to Medicare regulations, the managed care plans must provide enrollees with all Part A and Part B benefits. However, Medicare Advantage plans are not required to provide enrollees the same access to providers that is provided under original Medicare.
The cost for your treatment is dependent upon the plan design. You could have a flat $20 copay, or you could be responsible for a percentage of the cost (co-insurance). Over the past few years, patients with Medicare Advantage plans have reported to IDF that most have a 20 to 30% co-insurance for treatment. Unfortunately, most of these patients picked the Medicare Advantage plan thinking it acted the same as traditional Medicare Part B and a secondary plan. Don't forget that if you choose an advantage plan, you are not eligible to obtain a secondary policy. Make sure you know the coverage before enrolling.
Since Medicare plans vary from state to state and even by counties within a state, you need to research what plans you are eligible for. You can contact your State Health Insurance Assistance Program (SHIP) to find trained counselors who can tell you the plans you are eligible for and assist you in finding the answers to your questions regarding coverage. To find your state's SHIP program contact information, go to http://bit.ly/SHIPprograms.
What will happen to my Flexible Spending Account funds?
If you've been utilizing a Flexible Spending Account (FSA) of Health Savings Account (HSA), you will want to check on your FSA.
An FSA is an account offered and administered by employers that allow employees to set aside pre-tax dollars out of their paycheck to pay for the employee's share of insurance premiums or medical expenses not covered by the employer's health plan. Typically, benefits or cash must be used within the given benefit year or the employee loses the money. In the past few years a new rule was created where employers can allow you to carry over up to $550 of your FSA balance from one year to the next. So the end of the year is a perfect time to check your account and check with your benefits or human resources department to see if their plan allows this rollover.
An HSA is a medical savings account available to individuals enrolled in a high-deductible health plan that meets certain federal rules for out-of-pocket costs. The funds contributed to an account are not subject to federal income tax at the time of deposit. HSAs are employer-established benefit plans that reimburse employees for specified medical expenses as they are incurred, and the employee contributes funds to the account through a salary reduction agreement and is able to withdraw the funds set aside to pay for medical bills. Funds roll over year to year if you don't spend them.
What if I have more questions?
IDF is here for you! The IDF Health Insurance Toolkit can provide you with information and resources, including comparison worksheets, to help you understand health insurance plans and make the best possible choice in your selection. Download your toolkit at the IDF Patient Insurance Center today: www.primaryimmune.org/patient-insurance-center.
If you have further questions, contact IDF: 800-296-4433 or www.primaryimmune.org/ask-idf.
This article originally appeared in the IDF ADVOCATE Fall 2016. Click here to read the full edition.