Finding A New Insurance Policy
Open enrollment is starting soon, so here is a quick rundown of what you need to know when shopping for a new insurance policy. If you live in Texas you need to know that Texas is a little different, but most of the rules are about the same everywhere else. Open enrollment starts November 1, 2018 and runs through December 15 Just go to Healthcare.gov and look for the plans available in your area. Not as many as there used to be and usually only about two for every county. One important thing is to check to see if the plan does not let you use your copay card towards your max out of pocket.
Knowing what plan to pick: I remember that when I started learning about all of the different plans it was overwhelming, and this is my job! There is a silver lining if you are a person in the bleeding disorders community however. If you order factor often, then you can basically pick a plan on the basis of picking one that most of your doctors and your favorite specialty pharmacy, like Specialty Therapeutic Care, are on, but you don’t have to be that worried about the Bronze, Silver or Gold levels. With all of the new co-pay programs that the manufactures have, I think it is best to choose a lesser expensive plan so long you qualify for one of the manufactures programs. That is one of the silver linings that you fall into right now if you have a bleeding disorder.
Most of the manufacturer co-pay programs pay up to $12,000, (on your first order if large enough) so there is no reason why you should have to pay a higher premium for a Silver or Gold plan with a lower max out of pocket, if your max out of pocket will be covered by a manufacturer. After that first month, your insurance should pay at 100% the rest of the year. Almost all of the plans are what they call integrated, and that means, that it does not matter how you meet your deductible, through the pharmacy or medical side of the plan. The max out of pocket is the most you will ever have to pay that year other than your premiums.
It is really a great thing for a person with a lifelong condition like hemophilia, and I cannot tell you how many guys I have helped pick policies who had close to a $200 monthly premium, and as soon as they place their first factor order, the rest was paid at 100% all year. There should not even be a co-pay the rest of the year. Of course you need to check, but most policies work that way and going to the doctor or getting your prescriptions filled, should not cost you anymore for the rest of the year. They even have a plan called a catastrophic plan that is available to young adults. This type of plan pays nothing until the entire max out of pocket is met – usually $6,600, so as you can see, that would be a terrible plan for most people, but if you order factor the day your plan is effective, then you should max it out and pay nothing as long as the claim is paid first.
Maxing out your plan: What does this mean? If you chose a Bronze plan with a $6000 deductible, and order your factor on January 1 or as close to it as possible, and if it gets paid through the pharmacy benefit, it usually gets paid electronically and it should then show that you have met your max out of pocket for the year soon after that.
If your factor gets paid through the Medical side of your insurance, that is different. You will need to know that it will not max you out until the claim actually gets paid or is applied to your deductible. Sometimes and you would need to call the insurance company, but when the claim is officially recognized in their system, then it applies your deductible and that is good to know because it could take up the three months to pay a claim on the medical side possibly. . This is very important because if you order factor on Jan 1, then go get an Xray on Jan 5th, for example, your factor claim probably will not have been paid or in their system, and you will be responsible for the cost of the Xray if it gets processed before the factor order. They will then send you a bill, so be careful! This happens all the time. It is a bit of a gamble, so if you are very worried, then that is where a Silver or Gold plan may be better for you, but you will pay higher premiums. Try to find out ahead of time if the factor will be paid on the medical or the pharmacy side of the plan. Most of the time it all works out and most plans now the factor is covered through pharmacy and you will not have to wait long.
If you lose your insurance any other time of the year, for any reason and as long as you have lapsed more than 60 days, then you can still get new insurance even though it is not open enrollment, you will just need to show a letter of credible coverage.
Sifting through the choices: I would start looking at plans that use the specialty pharmacy and doctors you want to use. If you get help with premium assistance through a non-profit like PSI, you should try to use a company that contributes to them in my opinion. If you pick an insurance company for instance, they have their own company pharmacy call and ask if they contribute to PSI. This is how non-profits like PSI have money to help you with premiums is from donations from the manufactures and Specialty Pharmacies and if you notice, sometimes they have to stop taking any new patients because there are more people that need help compared to amount of donations they have.
There are two ways to purchase insurance:
1. Once you find out what plans are available at Healthcare.gov you can purchase a plan there if you think you will qualify for a subsidy. Some basic guidelines are, if you make under about 11k a year, you probably will not be eligible. If you make over $45,000-$50,000, you probably will not get much. The best way if you are looking for a subsidy is to call them or go to the website and they will tell you for sure. If you are only able to get a very small amount, you might chose to just buy on open market directly form insurer.
2. The second way you can purchase is to go directly to the insurance company to purchase a plan after you have found the plans in your area on healthcare.gov. This is a much easier way to buy the insurance if no subsidy is involved. You need to also check because some policies are a little different if bought on Market Place vs bought directly and could have different benefits and probably narrower networks ect.
Good luck on your insurance hunt and if you use Specialty Therapeutic Care as your pharmacy you can always contact me at firstname.lastname@example.org , and I can help answer any insurance questions you may have.