Skip to main content
IDF logo
Smiling insurance worker helping couple

How to choose an insurance plan

When it comes to health insurance, you need to be your own advocate—and that starts with asking questions. It’s your responsibility to understand your plan, no matter how you and your family obtain coverage. You’ll want to find a plan that’s right for you because it can have a huge impact on your health and finances.
 

Choosing the right health insurance plan can be a daunting task. It’s crucial to understand your plan's details and make an informed decision to ensure both your health and finances are protected. Always review a plan's summary of benefits, drug formulary list, and provider network directory. 

Questions to ask before deciding on a health plan

  • What is the premium?
  • What is the out-of-pocket maximum?
  • What are the deductibles?
  • Is the deductible included in the out-of-pocket maximum, or is it in addition to the maximum?
  • How is immunoglobulin (Ig) therapy covered?
  • Do you have coinsurance or a flat copay for treatments and services you are likely to need?
  • Do you have options for site of care?
  • Are your physicians in the plan's network?
  • Are there out-of-network benefits?
  • Does the plan have a copay accumulator?

Choosing a private health plan

Unexpected medical needs can be costly and unpredictable, so it's important to understand the costs associated with your health plan based on your family's known health situations.

  1. Download and complete the Personal Health Experience Stat Sheet to identify and quantify the health services you and your family used in the previous 12 months. This list provides a list of benefits your new plan should include.
  2. Reference the glossary of insurance terms when needed.
  3. Ask your human resources representative, insurance agent, or marketplace agent to provide the following documents for each health plan you are considering:
    1. Benefit summary: an easy-to-understand summary of a health plan's benefits and coverage.
    2. Drug formulary: a list of prescription drugs covered by the health plan.
    3. Provider network directory: a list of providers contracted with the health plan to provide healthcare services.
    4. Health savings account (HSA) or flexible spending account (FSA) details, if provided.
  4. Download and complete the Health Plan Cost Comparison Worksheet to evaluate your potential plan costs based on your prior year's medical experience.

 Additional tips to consider:

  • Ask your human resources/benefits administration department, broker, or the health plan's customer service representative if you have questions about your options.
  • You may have the choice between EPO, HMO, POS, or PPO plan types. Consider the pros and cons of each type of plan.
    • Exclusive provider organization (EPO): A managed care plan in which services are covered only if you go to doctors, specialists, or hospitals in the plan’s network (except in an emergency).
    • Health maintenance organization (HMO): An insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO. Generally won’t cover out-of-network care except in an emergency, and may require you to live or work in its service area to be eligible for coverage.
    • Point-of-service (POS): A type of plan in which you pay less if you use doctors, hospitals, and other healthcare providers that belong to the plan’s network. POS plans may also require you to get a referral from your primary care doctor to see a specialist.
    • Preferred provider organization (PPO): A type of health plan that contracts with medical providers, such as hospitals and doctors, to create a network of participating providers. You pay less if you use providers who belong to the plan’s network. You can use doctors, hospitals, and providers outside of the network for an additional cost.
  • Check enrollment dates with your employer or the Affordable Care Act (ACA) marketplace.

Choosing a Medicare plan

Similar to choosing a private insurance plan, you need to do a thorough evaluation of your choices to determine the Medicare plan that works best for you. Medicare is broken into several parts:

  • Part A: Original Medicare that covers inpatient hospital stays, skilled nursing facilities, hospice care, and some home healthcare.
  • Part B: Optional part of original Medicare that covers doctor’s visits, preventative care, medical tests and imaging, and some prescription drugs, including immunoglobulin (Ig) replacement therapy for certain PI diagnoses.
  • Part C: Also known as Medicare Advantage coverage; these privately run plans must cover Part A and Part B services and benefits but can impose their own rules, including preferred provider networks, drug formularies, cost-sharing, prior authorization, step therapy, and referral requirements.
  • Part D: Optional prescription drug coverage, which includes Ig replacement therapy for all other PI diagnoses.
  • Parts F & G: Optional supplemental coverage known as Medigap coverage.

During enrollment, you must choose between either original Medicare (Parts A & B) or a Medicare Advantage plan (Part C). Only those enrolled in original Medicare that do not have other, secondary insurance can opt to purchase Medigap coverage (Part F or G).

Starting with the 2024 open enrollment period, those who purchase Part D drug plans or Medicare Advantage plans with Part D drug coverage can also enroll in the Medicare Prescription Payment Plan. People who use this payment option will receive a monthly bill for their prescriptions covered under Part D from their plan instead of paying the pharmacy directly when the prescriptions are filled. The plan is intended to help seniors manage their monthly expenses but does not lower overall drug costs. Use this tool to decide whether the payment plan is right for you.

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. Contact your State Health Insurance Assistance Program (SHIP) to find trained counselors who can tell you which plans you are eligible for and assist you in finding the answers to your coverage questions.

Medicare eligibility and enrollment

Most people become eligible for Medicare when they turn 65 years old. If you are already collecting social security at age 65, you are automatically enrolled in Medicare. If not, you must enroll during a 7-month “initial enrollment” period to avoid paying a penalty. The initial enrollment window includes the three months before you turn 65, the month of your 65th birthday, and the three months after you turn 65. 

If you miss your initial 7-month enrollment window, you can enroll with a penalty from January 1 through March 31 each year, which is known as the “general enrollment” period. There are also special enrollment periods for those in specific situations to enroll without a penalty.

To enroll in Medicare due to disability, you must qualify for and collect social security disability benefits for two years before you are eligible.

After your first enrollment, there is an “open enrollment” period when you may join, switch, or drop Medicare plans. It takes place each year from October 15 to December 7, with coverage starting January 1.

Coverage for Ig therapy

Under original Medicare, coverage for Ig therapy depends on your specific diagnosis. For certain PI diagnostic codes, Ig therapy, whether intravenous (IVIG) or subcutaneous (SCIG), is covered under the Part B medical benefit at 80% with no out-of-pocket maximum. This Part B coverage includes the supplies and nursing necessary for home IVIG, if needed. Other insurance or a Medigap plan (Part F or G) is required to cover the remaining 20%.

For all other PI diagnoses, Ig therapy is covered under Part D. Starting in 2025, Part D plans will have a $2000 out-of-pocket maximum each year. 

Another option is a Medicare Advantage plan (Part C), which is sold as an “all-in-one policy” and acts more like private insurance. Part D drug coverage may be included in Medicare Advantage plans, but sometimes it must be bought separately as a stand-alone Part D plan. Medicare Advantage plans decide whether your Ig therapy is billed through part B or Part D. Patients with Medicare Advantage plans have reported to IDF that most have a 20-30% coinsurance for treatment. If you choose an advantage plan, you are not eligible to obtain a secondary Medigap policy.

Medicaid eligibility and enrollment

You may qualify for free or low-cost healthcare through Medicaid based on income and family size. Eligibility rules vary from state to state. In all states, Medicaid provides health coverage to some children, parents, pregnant women, elderly people with certain incomes, and people with disabilities. Some states have expanded their Medicaid programs to cover other adults below a certain income. 

There are two ways you can apply for Medicaid:

Ask IDF

Getting answers can help create peace of mind. Ask us anything and we’ll consult with experts.

Submit a question

Do you have information to help me select a health insurance plan to cover my needs?

Selecting a health insurance plan can be a challenging process. Basic information to navigate insurance is available for the PI community.

Answers to specific 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, or by contacting the insurance company. When speaking to an insurance representative, you should be able to receive answers to all of your questions. If not, ask to speak to someone who can answer them.

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 select it than to find problems and hidden costs after you have made a decision. Please remember, it is okay to ask questions until you receive answers when communicating with insurance representatives.

Are prior authorizations required for Ig therapy?

Yes, prior authorizations are required for Ig therapy. These can take anywhere from a couple of days to a few months. Insurance companies require re-authorizations, including updated lab work and clinical notes (from an office visit) every 6-12 months. Some insurance companies are becoming stricter and require this every 1-3 months. 

If you have further questions or are diagnosed with PI and looking for more support, please reach out to us at 410-321-6647.

Couple trying to understand insurance

Common health insurance terms

Get clarity on what key terms and acronyms mean to you.

Browse glossary
Man sitting at his desk on the phone.

Filing appeals and complaints

If your insurer denies a claim, you have the right to appeal. You can also consider filing a complaint.
 

Know your rights
IDF logo
Immune Deficiency Foundation
7550 Teague Road, Suite 220
Hanover, Maryland 21076

P: 410-321-6647

Seal Platinum logo
Charity Navigator logo
CFC logo
NHC logo
Nord logo

The Immune Deficiency Foundation improves the diagnosis, treatment, and quality of life for every person affected by primary immunodeficiency.​

We foster a community that is connected, engaged, and empowered through advocacy, education, and research.

Donate

Combined Charity Campaign |  CFC# 66309

© 2024 Immune Deficiency Foundation | Immune Deficiency Foundation is a 501(c)(3) organization (EIN: 52-1214782)