Health Insurance Basics
What is health insurance? Most simply, health insurance is a contract between you and the insurance company that says that the insurance company will pay a portion of your medical expenses if you get sick, hurt or need an annual checkup and have to visit a doctor’s office or hospital.
Why is it important to have health insurance? Without health insurance, it is more difficult to afford medication and services.
What types of health insurance are there? There are many different types of health insurance companies, programs and plans in the United States, each serving different populations with different needs. Two general categories are:
- Public programs – government-funded programs to help you pay for your medical treatments. Examples include Medicare, Medicaid and Health Insurance Marketplace plans. Each program has different eligibility requirements and application processes.
- Private plans – plans funded by either private insurance companies or private employers. Enrollment requirements and costs are determined by either the insurance company or the private employer.
Finding the Right Plan
Don’t be stumped when it comes time to finding health insurance once you turn 18. Here are some suggestions for finding coverage:
- Stay where you are. If you’re already covered under your parents’ health insurance plan, the Affordable Care Act requires that your insurance company allow you to stay on your parents’ plan until your 26th birthday. Don’t worry though − you don’t have to live with your parents to be on their insurance plan. You can even get married and still qualify!
- College: more than an education. If you are attending or planning to attend college, ask if the school has a student health insurance plan.
- Work for it. If you’re going to be working, look for jobs with health insurance as an employee benefit.
- The government. Both your state and federal government have assistance and insurance options that you can access. See PHA’s Insurance 101 page for more information.
Do a quick search yourself! Find insurance options in your state
Choosing a Health Insurance Plan
Your insurance is going to be most effective (meaning less out-of-pocket costs for you) if it covers (pays for) your prescription medications, doctor’s visits, etc. Call your potential insurance company or read the insurance company’s plan of benefits to find the answers to these important questions:
- Is my current doctor (PH specialist) covered (paid for) by this plan? You’ll want a plan that covers your PH specialist. If you’re planning to transition to an adult specialist, you’ll want to make sure that the plan covers visits to your new specialist.
- Will this plan cover my medications? Check to see if your plan will cover the PH medications you’re currently taking. If you anticipate taking another PH medication in the future, ask if the plan covers these medications as well.
- Is my PH center in-network for this insurance? If your center isn’t in-network, meaning not included in the company’s list of hospitals and doctor’s offices that they contract with, you may have to pay more out-of-pocket or need to obtain prior authorization for their services and tests (even if they’re routine).
- What are the total out-of-pocket costs and can I afford to pay them? Calculate how much you think you’ll pay monthly for medical needs and then ask yourself if you can afford it. Keep in mind:
- Is there a premium (monthly payment) you’ll have to pay to keep the insurance?
- Is there a deductible you’ll have to pay before the plan will start paying for benefits?
- How much will you have to pay each time you see your doctor or fill a prescription?
www.PHAssociation.org/HELP lists resources that may help you reduce your out-of-pocket costs for your PH medication.
- If I were to require a transplant in the future, will this insurance cover organ transplant?
Know Your Health Insurance Rights
Certain laws protect your rights. As you learn how to manage your insurance, keep these laws in mind:
- Americans with Disabilities Act (ADA) prohibits discrimination on the basis of disability in employment, state and local government, public accommodations, commercial facilities, transportation, and telecommunications.
- Affordable Care Act (ACA) is a comprehensive healthcare reform bill enacted in 2010. It prohibits discrimination in health insurance coverage based on pre-existing health conditions, allows young people to stay on a parent’s or guardian’s health insurance until age 26 and establishes the health insurance marketplace for the purchase of individuals health insurance coverage that meet minimum coverage requirements and do not have annual or lifetime benefit caps.
- Consolidated Omnibus Budget Reconciliation Act (COBRA) allows you to temporarily keep your health insurance policy if you are losing or changing jobs.