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. The following information will help you make the best possible choice in selecting an insurance plan.

Private Insurance

Determining which health plan is most appropriate for your needs can often be a difficult process whether it is an individual or family policy offered through your employer (a group health plan) or one you acquired as an individual. There are many things to consider when reviewing your options. These considerations fall under two categories: cost and benefit design. Most people first consider the cost of a plan when making a decision. Our goal is to provide you with tools to help you compare and evaluate the cost and benefits of various plans that may be offered to you by an employer or an insurance marketplace in your state. Questions typically asked by people when choosing a plan 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) therapy covered?
• Do I have a coinsurance or a flat co-pay?
• Do I have options for site of care?
• Are my physicians in the plan’s network?
• Are there out-of-network benefits?

Answers to some of these questions, relative to cost and generally covered benefits, can be found by reviewing a plan’s summary of benefits, drug formulary list and provider network directory. However, sometimes you will need to find out more information from the plan to get all of the information you need. While this is often considered a tedious process, it is one of the most important steps you can take to ensure that a plan meets your needs. It is better to know everything you can about your plan before you pick it than finding out problems and hidden costs after you have made a decision.

It is important to remember that once you choose a plan, you cannot change until the next open enrollment period unless you experience a qualifying life event.

Getting Started

1. Download and complete the Personal Health Experience Stat Sheet. This document was designed to identify and quantify the health services used by you and your family in the previous 12 months, providing you with a list of benefits your new plan should include.
2. Reference the Glossary of Terms when needed.
3. Collect from your Human Resources representative, insurance agent, or Marketplace the following documents for each health plan being offered (Note: often you will be provided a link to this information on the insurance carrier’s website).

a. Benefit Summary – Health insurers and group health plans are required to provide you with an easy-to-understand summary of a health plan’s benefits and coverage.

b. Drug Formulary – Health insurers maintain a formulary (sometimes referred to as a Preferred Drug List or PDL), which is a list of prescription drugs, both generic and brand name, that are covered through your health plan. Formularies classify drugs by different cost tiers that define the plan member’s co-payment (co-pay) amount and/or coinsurance levels. Typically, generic drugs require the lowest co-pay from plan members.

c. Provider Network Booklet – A provider network is a group of providers (such as physicians, hospitals, skilled nursing facilities, pharmacy or other licensed, certified institutions, or health professionals) that have contracted with the health plan to provide healthcare services to plan members at agreed upon billing rates. Depending on the plan’s design, members who receive care from a provider not included in the network may have less or no coverage for that provider and/or service received. It is important to note that many insurers offer several different plan options, each of which may have a different provider network. It is important to review the provider network for each plan.

d. Health Savings Account (HSA) or Flexible Spending Account (FSA) – If your employer provides either of these programs, printed copies of the details will be helpful. A Health Savings Account 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. Healthcare Flexible Spending Accounts are employer-established benefit plans that reimburse employees for specified medical expenses as they are incurred. 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.

4. Download and complete your Health Plan Cost Comparison Worksheet. One way to evaluate your potential plan cost is to base your review on your prior year’s medical experience. Using the information included on your Personal Health Experience Stat Sheet, the plan’s summary of benefits, and drug formulary list, fill in each section that applies on the worksheet.

It is important to remember that unexpected medical needs often arise, and their costs are often unpredictable. It’s our hope to provide you with a general idea of the predictable costs associated with your health plan based on your family’s known health situations.

While these documents may answer many of the questions important to choosing the appropriate plan, there may be some questions that require additional resources. To answer these questions, begin by contacting your human resources/benefits administration department, broker or your health plan’s customer service representative.

You may find that you have the option to choose between multiple plan types and designs such as HMO, PPO, POS or EPO. The Health Plan Cost Comparison Worksheet was designed to help in performing a side-by-side comparison of your plan options by helping to identify covered benefits and out-of-pocket costs associated with each. The chart can be used in two ways: to make general comparisons between health plans or highlight the costs and benefits specific to your individual needs.

Check enrollment dates either with the insured’s employer (whether yourself or a family member). If choosing a plan in the Marketplace, click here to view enrollment dates.

What if I’m eligible for Medicare?

Similar to choosing a private insurance plan, 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 above when you choose a plan.

If you receive Ig therapy, check out how your treatment will be covered. Coverage largely depends on one’s specific diagnosis and their site of care. In general 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 obtaining a supplemental/medigap plan (Part F or G) 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 co-pay, or you could be responsible for a percentage of the cost (coinsurance). Over the past few years, patients with Medicare Advantage plans have reported to IDF that most have a 20 to 30% coinsurance for treatment. Unfortunately, most of these patients picked the Medicare Advantage plan thinking it acted the same as traditional Medicare Part B and a medigap plan. Don’t forget that if you choose an advantage plan, you are not eligible to obtain a secondary policy.

Also, CMS has a new policy for Medicare Advantage plans that allows the plans the option to apply step therapy to Part B drugs that are physician-administered. Step therapy usually requires you to start with the lowest cost option and then you can “step-up” to higher cost products if there are medical reasons for the change. If you are well established on a product and do not wish to change your treatment plan you may want to avoid the Part C option or at least confirm whether the plan will use step therapy.

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.   

Finally, if you decide on Traditional Medicare you will need to enroll in prescription coverage (Part D) as well. You can use Medicare’s Part D Plan Finder tool:  https://www.medicare.gov/find-a-plan/questions/home.aspx

Check the Medicare website for enrollment dates: https://www.medicare.gov/.

If you have further questions, contact IDF: 800-296-4433 or www.primaryimmune.org/ask-idf.