As you review your insurance coverage during open enrollment season, be aware of hidden practices that could raise your out-of-pocket costs.
If you use a copay card or grant for your pulmonary hypertension (PH) medications, try to confirm how that money will be applied to your deductible and out-of-pocket maximum. Many health insurance companies now use strategies that allow them to make money from copay cards and grants while keeping patients’ out-of-pocket responsibility high.
Here are a few things to look for:
Plans that use copay accumulator models accept copay cards but don’t apply them to deductibles or out-of-pocket maximums. For example, a plan with a $3,000 deductible would apply your copay card to the cost of your medication. However, if the balance on your card ran out before the end of the year, you would have to pay your full deductible. In addition, the plan wouldn’t apply the amount of your copay card to your out-of-pocket maximum. That means you would reach your out-of-pocket cap later in the year, if at all.
Short-term, limited-duration health plans also pose potential risks. The low-premium plans are intended to provide minimal health insurance during temporary coverage disruptions. But they don’t have to cover preventative care, prescriptions or other essential health benefits. The plans can refuse coverage based on preexisting conditions, so people with PH are unlikely to be approved.
“Caution about extremely low-cost plans is warranted,” says Katharine Kroner, the Pulmonary Hypertension Association (PHA)’s senior director, advocacy and treatment access.
Health insurance plans generally don’t want to tell potential customers if they have copay accumulators or other cost-shifting practices. Organizations like the Patient Advocate Foundation (800-532-5274) and Medicare Rights Center (800-333-4114) can help you identify plans with cost-shifting practices and find health insurance plans that are better for people affected by PH.
To reach PHA’s Treatment Access Program, email us, or call 301-565-3004 x749.