If you have a bleeding disorder, you must have health insurance coverage. Managing a bleeding disorder costs a lot, so you need to know the ins and outs of your policy—what it does, and doesn’t, cover. And with healthcare policy changing rapidly, more than ever consumers must stay educated about their insurance options.
Following is an overview of the different kinds of insurance available and what to consider as you evaluate your coverage ahead of this year’s open enrollment period:
Types of Insurance
• Employer-sponsored health insurance
If you are covered by your employer’s group health plan, check with the human resources department to find out when your company’s open enrollment period begins and ends. During this period you can change your coverage. If your employer makes adjustments to coverage or there is more than one choice of health insurance plan, evaluate which options work best for your needs as a person with a bleeding disorder. You may decline your employer’s health coverage and purchase other insurance, but keep in mind that most employers subsidize the cost of your monthly premium so if you buy your own insurance you won’t receive this subsidy.
• If you don’t have healthcare coverage through your job
You can purchase an individual healthcare plan for yourself and your family. Such plans are available through what’s called the health insurance marketplace (also referred to as an “exchange”), or they can be purchased outside the marketplace (i.e., “off-exchange”) directly from health insurers.
Based on your income and family circumstances, you may qualify for subsidies to help pay for health insurance. If you do qualify for financial assistance, you’ll purchase a plan through the federal government’s (or your state’s) marketplace. If you don’t qualify for subsidies, you may want to see what’s available off-exchange. Plans offered outside the government’s health insurance marketplace may differ from those available on the federal- and state-run marketplace. An off-exchange plan may better suit your healthcare needs.
To shop for and purchase a plan from the health insurance marketplace, go to healthcare.gov. For 2019, health insurance marketplace open enrollment runs from November 1, 2018, to December 15, 2018. Plans purchased during open enrollment begin coverage starting January 1, 2019.
To shop for and purchase a plan outside the health insurance marketplace, go to finder.healthcare.gov.
• If you have public health insurance (Medicaid, Medicare and CHIP)
Depending on changes to your income and family situation, you may or may not qualify for a public health insurance program—or you may be able to apply for a program for the first time depending on your income or your age. Your HTC social worker can help you determine your eligibility and help you apply. To get an idea if you’d likely be eligible for Medicaid, try the Kaiser Family Foundation Health Insurance Marketplace Calculator.
Evaluating Plans
No matter what type of insurance you end up with, you need to understand what it covers before you buy it. Make sure you know the answers to important questions such as: Is clotting factor covered and is it tiered? Is my hemophilia treatment center (HTC) in network? Do I need a referral to see a specialist (e.g., a hematologist)? What services require prior authorization? Are physical therapy services covered?
Before purchasing any plan, carefully evaluate the following:
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.
Drug Formulary – Health insurers maintain a formulary (sometimes referred to as a Preferred Drug List or PDL), which is a list of prescription drugs, covered through a health plan. Formularies classify drugs by different cost tiers that define the plan member’s copayment (copay) amount and/or coinsurance levels.
Provider Network Booklet – A provider network is a group of healthcare providers (e.g., physicians, hospitals, skilled nursing facilities, pharmacies) that have contracted with the health plan to provide 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. Many insurers offer several different plan options, each of which may have a different provider network. Review the provider network for each plan you consider to ensure it has the doctors and services you need.
Learn more
See the Healthcare Coverage section of the NHF website for more on choosing the health plan that is right for you.