10 Facts About Health Insurance Coverage in the United States


The Immune Deficiency Foundation recently offered guidance for patients with immune deficiencies.

A person with a rare or serious disease needs a double dose of education: after learning all about their condition, patients and caregivers must then understand how to manage health care bills and coverage insurance.

It can be overwhelming, but the Immune Deficiency Foundation recently held a webinar to help people with immunodeficiency diseases understand how health insurance works.

Stephanie Steele, IDF IP Community Engagement Manager, and Abraham Yunis, IDF Director of Payer Relations and Policy, offered these tips. We’ve also added advice from Kris McFalls, CSL Behring’s Senior Director of Reimbursement and Access.

1. Know what to look for in an insurance plan. Check www.healthcare.gov for options. Consider your current providers and if you want to stay with them, choose a plan that includes them as “in-network”, which means they accept your insurance and your out-of-pocket will be lower. To be sure, call the insurance company to confirm this before committing to a new plan.

2. When choosing between several plans, compare the deductibles (the amount you will have to pay for care each year, in addition to the premium you pay for the policy itself) and the maximum disbursements (the maximum amount you have to pay each year before your insurance covers all your costs).

3. Learn about prescription drug “copay accumulators” and “copay maximizers” that may prevent a copay manufacturer’s assistance from applying to the deductible. a person. If it’s not clear, call Member Services and ask specifically if manufacturer support counts toward your deductible and disbursed expenses, McFalls said.

4. Will your specific drug be covered by your insurance plan? It depends and it can be difficult to know this before choosing a plan. If your medication is not on the plan’s “Formulary”, you have a choice. Your doctor can request an off-form exception appeal, but you’ll need detailed documentation to support it. It’s important to remember that just because your medications aren’t on the formulary doesn’t mean they aren’t necessarily covered, McFalls said. The form only tells you about prescription benefits. Your medication may be covered under the medical benefit. If in doubt, ask about your home infusion benefit, she said.

5. If you’ve just been diagnosed, be aware that your plan may require specific types of lab tests on record before they’ll approve coverage. “It’s very important that you make sure you have a thorough workup when you’re diagnosed,” Steele said.

6. Keep good medical records and save your documents, especially when you are first diagnosed. Keep copies of all reports of your lab work and full details of your diagnosis – these can be helpful when changing plans or appealing a coverage decision. Take advantage when your health care provider offers access to electronic records, McFalls said. This helps ensure that all of your records are properly documented and that your healthcare providers have copies of all lab work and reports.

7. If your employer has chosen your plan and it creates a burden for you, bring it to their attention, usually through the Human Resources (HR) or Benefits office. The company may consider offering different options next year. A patient may be afraid to tell an employer about their medical issues and need for treatment, McFalls said, but be aware that human resources departments are bound by confidentiality laws and must keep these details confidential.

8. Look for ways to plan your health care expenses, such as Flexible Spending Accounts (FSA) or Health Savings Accounts (HSA), which allow you to deposit money, pre-tax, into a card or account.

9. Ask questions. Private plans usually have a case manager or other person available to help answer any questions you have about your plans. You can also contact patient advocacy groups like IDF, which have experts and information that can help you.

10. If coverage is denied, it’s not the end of the road, Steele said. Your doctor can call the insurance company to explain the situation, which is called a peer review. He or she may also ask for the credentials of the person who declined coverage, as it is important to have a competent specialist review your case, she said.

Watch the full IDF webinar


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