Now is the time to renew health insurance coverage purchased through a state or federal health insurance marketplace, also known as an insurance exchange. Marketplace open enrollment has begun and continues through Dec. 15. The federal government website – www.Healthcare.gov – has tools to sign up for new coverage, change plans or renew coverage for the 2019 plan year. During the application or renewal process, participants will be alerted if they qualify for financial help to pay health insurance costs.
Find Help Choosing Coverage
Individuals with pulmonary hypertension (PH) seeking health insurance coverage may want to review their options with a trained health insurance navigator. Both the Caring Voice Coalition (888-267-1440) and Patient Advocate Foundation (800-532-5274) offer this service. In addition, some PH care teams include a financial counselor or social worker knowledgeable about insurance options.
Caution: Beware Limited Coverage Plans and Copay Accumulators
Most health insurance marketplace plans include essential health benefits, a set of 10 areas of health care that are at least partially covered by every plan. These include emergency care and hospitalization; prescription drugs; laboratory services; pediatric care; preventive and wellness services; and maternity and newborn care. During the current open enrollment period, participants may see an increase in short-term plan options. These options tend to be cheaper, in part because they are not required to include coverage for the 10 essential health benefits. In addition, while most marketplace plans cannot charge more to people with pre-existing conditions, short-term plans have more flexibility. Short-term marketplace plans can be useful as a bridge between other types of coverage in select circumstances, however PH-community members should be cautious as short-term coverage may be quite limited in scope.
A word of caution also applies to any insurance plan that includes a copay accumulator or accumulator adjustment program. Copay accumulators are a cost-management strategy used by some health insurance companies that can place a financial burden on PH patients. Earlier this year, the Pulmonary Hypertension Association (PHA) covered copay accumulators in more detail.
Questions to Consider
PH patients who are reviewing their coverage options independently may want to consider the following:
- What is the premium, or monthly cost, that I would pay to maintain this health insurance?
- Will I have to pay a deductible, or initial amount, before coverage begins? If so, how much is it?
- Does the health insurance I am considering include prescription drug coverage, or do I need to purchase that separately?
- What medications will I take in the upcoming year? Are these medications included in the health plan’s formulary?
- Will I need routine tests or hospitalization in the upcoming year?
- How much of the total cost of my anticipated medical care and prescriptions will this plan cover? For example, for each of my PH medications, will I be charged a set dollar amount, called a copay, or will I be responsible for a percent of the drug price, called a coinsurance?
- Would I be better off paying a higher monthly premium for a plan that covers more of my anticipated costs?
- Does the pharmacy network for this plan include the specialty pharmacy that delivers my PH medications?
- If I use a co-pay card or other financial assistance, will this plan count my grant or coupon toward my deductible and out-of-pocket maximum?