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Health Insurance: What You Need to Know before the End of the Year

November 19, 2018

As the end of 2018 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 or if I am shopping the marketplace?

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 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.

Open enrollment for the Marketplace is November 1 – December 15, 2018 for January 1, 2019 start date.

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 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 for which plans you are eligible. 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 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: www.medicare.gov/find-a-plan/questions/home.aspx.

Open enrollment for Medicare is October 15 – December 7, 2018 for January 1, 2019 start date. Learn more at: www.healthcare.gov.

What do I do if I have met my annual deductible for 2018?

If you have met your annual deductible for 2018, 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. Begin 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 or human resources department for assistance.

What will happen to my Flexible Spending Account funds?

If you have been utilizing a Flexible Spending Account (FSA) or 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. New rules have allowed employers to choose one of two options to employees, the carry over option or the grace period option.

The carryover options allows you carry over up to $500 of unused funds to the following plan year. The grace period option allows an employee to incur eligible expenses for 2 months and 15 days. So, if you plan year ends on December 31 you have until March 15 of the following year to use the funds.

The end of the year is a perfect time to check your FSA account and check with your benefits or human resources department to see if their plan allows one of these rules.

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 do not spend them. For 2019, you can contribute up to the annual maximum amounts of $3,500 for self-only plans and $7,000 for family plans.

What if I have more questions?

IDF is here for you! The IDF Patient Insurance Center can provide you with information and resources to help you understand health insurance plans and make the best possible choice in your selection. Check out the IDF Patient Insurance Center today: www.primaryimmune.org/insurance.

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

 

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