managing the maze of insurance · understanding health insurance plans understanding health...
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Practical Insights for Patients
Managing the Maze of Insurance
Practical Steps for PatientsIt’s very important to understand how your health care insurance works. So, whatever your current health coverage, you should take practical steps to understand your plan and get the coverage you need. This patient guide offers information that can help you do that.
Using this Guide
This guide will help you
• Understand the basics of health insurance (page 4)
• Figure out how to get and pay for the medicine you need (page 16)
• Find answers to common questions (page 18)
• Find resources to help you manage your health care costs (page 21)
• Get a list of services and support (page 25)
Table of Contents
Understanding Health Insurance Plans .........................................................................4—Let’s Define a few of the Terms Used by Health Insurers
—Types of Private Insurance
—What is Medicare?
Prescription Drug Coverage: How to Get the Medicine You Need ..................... 16—Key Phrases about Prescription Medical Plans
—How do I get my Prescription Medicine Covered if I have Private Insurance
Common Questions and Things to Remember ........................................................ 18—What to do if Coverage is Denied
—Appeals are Common
Key Steps to your Healthcare Coverage .....................................................................20— Partner with your Health Care Team to Understand your Treatment Plan
and Health Care Coverage
—What Does my Explanation of Benefits Letter Mean
Managing Your Healthcare Costs ................................................................................. 21—What are your Financial Challenges in Paying for Health Care
—How Can I Get Help Paying for my Medicine?
Frequently Asked Questions (FAQs) ............................................................................23
Helpful Resources ............................................................................................................25
Glossary Terms ..................................................................................................................27
My Important Contacts and Health Insurance Information .................................. 31
Table of Contents
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Understanding HealthInsurance PlansHealth Insurance is an Agreement
Health insurance is an agreement between you and your insurer. In this agreement, you pay a monthly fee to the insurance plan, called a premium. In return, the insurer agrees to help pay for your medical bills and/or prescription medication expenses when you need care.
Health Insurance Covers:• Clinic/doctor’s visits
• Tests
• Hospitalization
• Medications
Let’s Define a Few of The Terms Used by Health Insurers Eligibility: The right to health care insurance if you meet the requirements of the insurer
Coverage: The amount of protection your health insurance policy gives you
Premium: The amount the insurance company charges you for your plan. It is usually paid each month
Deductible: An amount that your insurance plan says you must pay first each year before the insurer begins to pay for your care
Copayment: A dollar amount you pay when you have a health care visit or pick up medicine. Your deductible must be paid first
Coinsurance: A percentage of the cost for health care that you pay after you have paid your deductible. If you must pay 20% of the cost, the insurer will pay 80%. These amounts vary in different plans
Caps/lifetime limits:
• A maximum amount that an insurance company will pay for your health care in one year (caps) or for the entire time you have the insurance (lifetime limits)
• The Affordable Care Act (see p. 8) stopped insurers from adding caps or lifetime limits to plans
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Essential health benefits:
• Ambulatory patient services (outpatient care you get without being admitted to a hospital)
• Emergency services
• Hospitalization (like surgery and overnight stays)
• Pregnancy, maternity, and newborn care (both before and after birth)
• Mental health and substance use disorder services, including behavioral health treatment (this includes counseling and psychotherapy)
• Prescription drugs
• Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions to gain or recover mental and physical skills)
• Laboratory services
• Preventive and wellness services and chronic disease management
• Pediatric services, including oral and vision care (but adult dental and vision coverage aren’t essential health benefits)
Provider Networks: A group of health care providers, hospitals, clinics, and pharmacies who sign a contract with your insurer to provide care for you at a certain price.
• In-network: These are the health care providers who have signed a contract with your insurer
• Out-of-network: These are health care providers who have not signed a contract with your insurer. They may charge you more for your care
Insurers/payers: Insurance companies, the government, or employers who pay for part of the cost of health care for those who have insurance
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Private Insurance Plans: Commercial
Through Your Employer
• You may be able to buy insurance through your employer
• The Affordable Care Act requires employers with more than 50 employees to offer health insurance to full-time workers
Through Health Care Exchanges
• The Affordable Care Act allows you and owners of small businesses to buy health care insurance from a Health Care Exchange or Marketplace
• No one can be turned down or charged more for pre-existing conditions (any health disorder you had before you purchased insurance)
• Many people can receive tax credits to help pay for this insurance
Through your own purchase
• You can also purchase individual or family insurance directly from insurance companies or through an agent or broker
Public Insurance Plans: Government
Medicare
• Medicare is health insurance the government offers to people who are 65 and older and for some people who have certain disabilities
• To see if you are eligible, call your state Medicare office or look online at www.mymedicare.gov
Medicaid
• Medicaid is health insurance the government offers to people who have low incomes
• Each state decides criteria for eligibility
• Contact your state Medicaid office for eligibility or for insurance eligibility consideration, apply at www.healthcare.gov
Table 1. Plan Eligibility
Types of Insurance Plans: Private (Commercial) or Government There are two kinds of insurers: private companies and government programs.
• Private health insurance plans are offered by privately owned insurance companies. You can purchase plans through an employer, directly from an insurance company or through a state health insurance Marketplace or the federal government health care exchange, healthcare.gov.
• Government Programs include Medicare and Medicaid.
– Medicare is public health insurance for Americans aged 65 and older and for some people with certain kinds of disabilities.
– Medicaid is another kind of public health insurance for low-income families who cannot afford private insurance.
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Types of Private Insurance
Fee for Service (FFS)
• You choose your own health care provider
• The insurer pays the health care provider or reimburses you for health care bills
• May be more expensive than other types of plans
• Are non-managed-care health insurance plans
High-Deductible Health Plan (HDHP)
• Plans have higher deductibles but lower monthly premiums
• You pay more health care costs before the plan starts to pay any of the costs
• In 2020, these plans have deductibles of at least $1,400 for individuals and $2,800 for families
• If you have this type of plan, you may also have a Health Savings Account (HSA). An HSA lets you set aside money you earn before you pay taxes. The money can be used for health care costs. In 2020, an individual can set aside up to $3,550. A family can set aside up to $7,100
Managed Care
Preferred Provider Organization (PPO)
• An insurer contracts with health care providers to create a network
• You can choose to see either in-network providers or out-of network providers. However, usually you will pay less if you see in-network providers.
Health Maintenance Organization (HMO)
• An insurer only pays for costs from health care providers who work for or contracted with the plan in a certain area of the country
• You may pay less as long as you use the plan providers
• You may need to choose a primary care provider who will give you referrals to see other doctors, such as oncologists, rheumatologists, orthopedists, and other specialists
Point of Service (POS)
• A plan that costs less if you use doctors, hospitals, and other health care providers in the plan’s network
• You must get a referral from your primary care doctor to see other doctors
Exclusive Provider Organization (EPO)
• A plan that covers services only if you use doctors, hospitals, and specialists in the plan’s network
• You do not need to choose a primary care doctor
• Costs of care by providers out-of-network are not covered by the plan, except in emergency situations
Table 2. Types of Private Insurance
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Other Types of Private Insurance • Catastrophic Coverage
− Plans with low premiums and very high deductibles for serious sicknesses or injuries
− Generally, these plans can only be purchased by people younger than 30
− The deductible is $8,150
• Disability insurance
− Plans that pay part of your salary if you have an injury or illness that prevents you from working
• Hospitalization insurance
− Plans that cover hospitals stays and doctor charges while you are in the hospital
− May pay for a hospital room, surgery, tests, and more
− Maybe limits on what the plan pays
• Long-term care insurance
− Plans for people who are elderly or have disabilities and receive care at home or in a facility
− Help is provided for activities of daily living (bathing, dressing, eating) rather than for health care
When You Don’t Have Private Insurance• You may qualify for government programs that include:
− Medicare
− Medicaid
− Veterans benefits
− Social Security Disability Insurance (SSDI) or
− Supplemental Security Income (SSI)• Ask your doctor, nurse, or case manager to help you find these other types of insurance.
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The Affordable Care Act (ACA)If you don’t have health insurance through an employer plan or a government program, you can buy insurance through the Health Insurance Marketplace. The Affordable Care Act, or ACA, created the marketplace. In 2010, the federal government passed the ACA to help protect people like you and make insurance cost less.
The ACA provides:
• Patient’s Bill of Rights
− Plans cannot deny you coverage because you already have a health problem (called a pre-existing condition)
− Plans cannot place caps or lifetime limits on costs for a health problem you already have
• Health Insurance Marketplace
− State offer health insurance plans to people and small businesses who have no health insurance
• Tax credits for low-income people
− The government gives people who are needy money to help lower their premiums if they buy plans through the health insurance marketplace
• Free preventive health care
− This care helps prevent disorders from starting
• Lower prescription drug costs for seniors on Medicare
• Out-of-pocket limits on what you pay per year: $8,150 for an individual and $16,300 for a family in 2020
• Open enrollment: November 1—December 15 of each year
− The time when you can sign up for the same plan or a new plan that will start January 1 of the next year
• Special enrollment: if you have certain life changes, you may purchase or change your plan at other times of the year
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What is Medicare? The US government provides health insurance for people who are 65 or older and for younger people who have certain disabilities. Medicare has 4 parts: A, B, C, and D. Table 3 shows you what is covered by each part and who can get each part.
Medicare Part Eligibility Coverage Cost Covered
Part AHospital Insurance(automatic)
• US citizens who are 65 and older
• Younger people with certain disabilities
• Free if you or your spouse worked and paid Medicare taxes or Railroad Retirement benefits for at least 10 years
• Care in the hospital
• Care in a skilled nursing facility
• Hospice care
• Home health care
• Most medicines you get while you are in a hospital or skilled nursing facility
Part BMedical Insurance (optional)
• US citizens who are 65 and older
• Younger people with certain disabilities
• A monthly premium is taken out of your Social Security, Railroad Retirement, or Civil Service Retirement checks if you choose to buy Part B
• Doctor and clinic visits
• Care from other health care providers not in the hospital
• Home health care
• Durable medical equipment (wheelchairs, walkers, etc)
• Some preventive services (screenings, shots, yearly well visits)
• Many medicines you get while at your doctor’s office or a clinic. Some of these medicines are
− Shots
− Medicines that are given through an infusion pump or nebulizer, including biologics and biosimilars
− Oral cancer medicines
− Oral anti-nausea drugs
• Part B requires you to pay 20% of the cost of these types of medicines after you have met your deductible
• In 2019, biosimilars are treated the same as other brand-name drugs in Part B
Table 3. Parts of Medicare
Original Medicare includes parts A and B. If you have parts A and B, you can buy part C, Medicare Advantage, or a Part D prescription drug plan.
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Medicare Part Eligibility Coverage Cost Covered
Part CMedicare Advantage (optional)
• You must have Medicare Parts A and/or B to buy Part C as an option
• All benefits of Parts A and B
• Usually prescription drug coverage
• Run by private insurance companies that Medicare approves
• May include other benefits for extra cost
• May lower out-of-pocket costs
• Medicines you get at the pharmacy. The amount you will have to pay for your medicine depends on the Medicare Advantage plan you have
Part D Medicare Prescription Drug Plan(optional)
• All who have Medicare Parts A and B can buy Part D as an option
• Pays for part of prescription medicine costs
• Run by private insurance companies that Medicare approves
• Medicines you get at the pharmacy
− All Medicare Part D plans have a minimum level of coverage
− The exact medicines that are covered and their costs differ by plan
− You may need to use certain pharmacies
• In 2019, biosimilars are treated the same as other brand-name drugs in Part D
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Prescription Drug Coverage with Medicare You can buy a prescription drug plan as part of a Medicare Advantage plan or as a Medicare Part D prescription drug plan.
Medicare Advantage (Part C) • Medicare Advantage is another way to get Medicare insurance.
− You will get complete Part A and B benefits
− You can get a Medicare Advantage plan even if you have pre-existing conditions (except end-stage renal disease)
− Medicare Advantage plans cannot charge more than Original Medicare for care like chemotherapy, dialysis, or skilled nursing care
− If you are in a clinical research study, some of the costs may be covered by the plan
• These plans are sold by private companies who Medicare approves
• Plans may be HMOs or PPOs, and they often include prescription drug coverage
− You may pay more if you choose a health care provider who is not in the plan’s network
Medicare Part D• You can buy Part D prescription drug plans to add to Original Medicare (Parts A and B)
• Medicare sets a minimum level of coverage for these plans
• Different Part D plans offer different benefits and cost different amounts
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2020
Amount you and your insurer pay for medicines each year before you hit the Coverage Gap
$4,020
Amount you pay for medicines while you are in the Coverage Gap
generic $0
brand-name 25% of cost
Amount you pay for the year before you get out of the Coverage Gap
$6,350 for all covered* medicines
Catastrophic coverage starts
Amount you pay for the rest of the year when you are receiving catastrophic coverage
Cost less than $72 $3.60
Cost more than $74 5% of cost
Cost less than $179 $8.95
Cost more than $179 5% of cost
What will medicines cost in and after the Coverage Gap?
*Covered prescription medicines are those that your prescription drug plan allows.
What is the Medicare Coverage Gap?The Coverage Gap is when Medicare Part D pays less for your medicines. After you and your insurer pay a certain amount each year for medicines ($4,020 in 2020), you enter the Coverage Gap. While you are in this Coverage Gap, you will pay more for your medicines. Then after you have spent an additional amount during the same year (a total of $6,350), you enter catastrophic coverage. During the rest of the year, you pay much less for medicines. The table explains how this works.
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Under the Affordable Care Act, the Coverage Gap was set to disappear in 2020, but it closed faster for brand name drugs in 2019.? Did you know?
If you receive Extra Help, you do not have a Coverage Gap. Extra Help is for people who struggle to pay bills. In 2020, people with Extra Help pay no more than $3.60 for generic medicines and $8.95 for brand-name medicines. (See Helpful Resources)
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What are my Medicare Options?
You have 2 options for Medicare insurance.
• Includes Parts A and B
• US government manages the plan
• You can choose any doctor or hospital that accepts Medicare
• Usually you will pay deductibles and coinsurance unless you have supplemental coverage (Medigap)
• Usually you will pay a monthly premium for Part B
• Includes Parts A and B
• Insurance companies approved by Medicare sell these plans
• You can choose doctors in the plan network or pay more or all of the costs to see an out-of-network health care provider
• Usually you will pay a monthly premium for Part B
• Usually you will pay deductible, copayments, or coinsurance
• Plans offer different extra benefits and cost different amounts
• Join a Medicare Prescription Drug Plan
• Insurance companies approved by Medicare sell these plans
• Usually you must pay a monthly premium for the drug plan
• If you want prescription drug benefits, you must accept what your Medicare Advantage plan offers
• If your Medicare Advantage plan does not offer prescription drug benefits, you can join a Medicare Prescription Drug Plan (Part D)
Step 3: Do you want to buy Supplemental Coverage?
Step 3: Can you buy Supplemental Coverage?
• You can buy Medicare Supplement Insurance, called Medigap, if you have Original Medicare
• Private companies sell these plans
• Costs and benefits may be different among plans
• Check with your employer or union to see if you can get similar coverage from them
• You cannot buy Supplemental Coverage if you have a Medicare Advantage plan
Step 2: Do you want prescription drug coverage (Part D)?
Step 2: Do you want prescription drug coverage (Part D)?
Step 1: Original Medicare (Parts A & B) Step 1: Medicare Advantage Plan (Part C)
Option 1 Option 2
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Tier Levels Within a Typical Formulary
Prescription Drug Coverage: How To Get the Medicine You Need
Key Phrases for Prescription Medicine Plans You’ll need to understand how insurers decide which medicines they will pay for and know what happens if they don’t pay for a medicine.
• A formulary is a list of drugs that your plan covers. If a medicine you need is not on the plan’sformulary, you may have to pay a higher cost or all of the cost of the medicine
− Formularies put medicines into different tiers, or levels, and pay different amounts for themedicines
− Generics are medicines that are in Tier 1 and cost the least amount
− Brand-name medicines are listed in Tiers 2 or 3 and cost more than medicines in Tier 1
− The highest tier is Tier 4, and it contains specialty medicines − Formularies also may list some brand-name medicines as preferred. These usually cost lessthan brand-name medicines that are not preferred
− If a medicine is not on a formulary, contact your doctor for help
• A denial* is when an insurance company states that it will not pay for a medicine or a type ofmedical care
• You have rights as a person who pays for your health care insurance plan to appeal a denial.This means you may have to fill out paperwork with your doctor to explain why the medicineor service is needed
*See “What to do if My Claim is Denied” on page 17.
Generic Drugs (Tier 1)
Brand-Name Drugs (Tier 2/3)
Novel/Specialty Medications (Tier 4)
$
$$
$$$
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How Do I Get my Prescription Medicines Covered if I Have Private Insurance? • It can be hard work to figure this out. With help from your employer or your insurer,
you can find out
− What medicines your insurer covers
− Which pharmacies you can or must use
− How much the medicine will cost you after the insurer pays its part
• Talk to your health care provider about the cost of medicines before they are prescribed
If your insurer denies coverage for a prescription medicine:
• Talk to your health care provider
• Talk to your doctor’s office manager or billing person
• With the help of your doctor, you may be able to send in another claim that explains why themedicine is needed
What to Do if My Claim is Denied.• First, know that questioning your insurer is common
− The Department of Labor estimates that 1 out of every 7 insurance claims is denied
− About half of the appeals that are filed are successful
• Second, keep a record of every time you call a doctor or insurer
− Write down who you spoke to and the date of the call
− Ask for copies of claim forms your doctor’s office submitted
Prescription Drug Coverage: H
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If you are denied coverage, you can appeal.? Did you know?
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Common Questions and Things to Remember
What to do if Coverage is Denied
Step 1 Call your doctor’s office and ask to speak to the office manager or billing person.
• Could there be a mistake in my bill?
• Was the service or medicine given according to health care guidelines?
• Was the medicine given correctly?
• Was the doctor or nurse required to do a certain task when giving the medicine?
• Were the policies of the insurer followed for the medicine?
Your answers may lead the office manager to revise a claim for you or call the insurer.
Step 2 Call your health insurance company and ask questions.
• Is it possible that someone made a mistake?
• If there is no mistake, how do I appeal the denial?
• If my appeal is denied, how will we work out a solution?
• Are there important deadlines that I must meet?
• Is there anything else I can do to get the service or medicine covered?
If something does not make sense, ask them to explain it another way. Know that you may be asked to send in more forms or copies of doctor notes.
What to do Questions to Ask Steps
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Step 3
Ask your doctor to write a letter of appeal, which is called a Letter of Medical Necessity. The doctor will explain the reason the treatment or medicine is needed. The letter is sent to the insurer.
If you are sending this letter to your insurer, be sure to:
• Attach a copy of the Explanation of Benefits youreceived and anything else that makes your case.
• Make and keep a copy of all the papers you send.
• Send the letter by registered mail.
Step 4 Call the drug company’s patient support number. It is usually a toll-free number.
Contact information for a drug company is often found on the product information sheet that came with your medicine.
Know, too, that specialty pharmacies offer the same patient support as drug companies.
Step 5 Write and send your letter of appeal.
Remember to include:
• Your policy number, claim number, groupnumber, and your name
− If there was a mistake in the originalinformation, include the correct information.
• A copy of the denial letter that shows whycoverage was denied
• A history of your illness and how it has beentreated (the same information will be in thedoctor’s Letter of Medical Necessity)
• What you want the insurer to do:
− Review the denial
− Approve coverage quickly
Appeals are Common
You should understand that appeals to insurance companies are common.
• The need to appeal denial of coverage should not be viewed as an end to therapy selection
• The Department of Labor estimates that one out of every seven insurance claims are denied
• While most people who are denied don’t appeal, half of those who do are successful
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Key Steps to YourHealth Care CoveragePartner with Your Health Care Team to Understand Your Treatment Plan and Health Care Coverage
What Does my Explanation of Benefits Letter Mean? Part of taking control of your own care is understanding the letter you receive from your insurer that’s called an Explanation of Benefits. It shows information about what the insurer has paid or not paid for each health care visit, medicine, or service:
• The service date
• The name of the health care provider
• Whether the health care provider was in-network or out-of-network
• The covered expense for the visit, prescription, or service
• The amount your insurer paid to the health care provider
• The amount you are charged (patient responsibility)
We all can make mistakes. Medical billing errors do happen sometimes.
• Keep and review your EOB letters
• If something doesn’t look right, call your insurer and ask about it
• Your health care team may include:
• But don’t forget you are the most important member of your health care team!You can make a difference in the health care you get.
• Come to appointments prepared, ask questions, and communicate concerns to your team.
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− physicians
− nurses
− medical assistants
− pharmacists
− lab professionals
− physical therapists
− family members
− social workers, and
− mental health professionals
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Managing Your Finances
Managing Your Healthcare Costs
What are Your Financial Challenges in Paying for Health Care?Paying for health care is a concern for many people. Health care can create money problems for you and your family. You may have these challenges:
• Less household income because you need to work less or stop workingbecause of your illness
• Expensive or unaffordable treatment
• Treatments of prescription medicines that your insurance companydoesn’t pay for
• Extra costs of getting to doctor visits, child care, a hotel if treatmentis far away, and in-home health care
Take matters into your own hands and ask for help from:
• Your insurance company case manager: this person is usually a nurse who worksfor the insurer and can help patients understand their policy
• A financial advocate: this person may be a close friend of family member whocan help you to stay on top of bills, insurance letters, and more
• Your employer: your employer may be able to call the insurer to request a changein the plan benefits or to have them review your appeal
• Your health care provider: ask your doctor about other treatment options that maycost less, and be sure to ask about the cost of treatments before you agree to them
• Depending on your treatment and side effects, you may want to take a medical leave(time off) from work. If you and your employer qualify under the Family and MedicalLeave Act (FMLA), you have the right to take an unpaid, job-protected medical leavewith continued health insurance coverage. The amount of time you are allowed totake off may vary. Talk to your social worker or your human resources departmentat work to get more details.
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Many groups give help to patients with serious illnesses or to older people with fixed incomes. Help is given to people with insurance, without insurance, or with poor insurance plans.
• Patient assistance programs (PAPs):these offer free or discounted prescriptionmedicines to people in need
• Community-based charitable programs(see Helpful Resources)
− Many community churches or otherorganizations can help you pay the costsof treatment
• Medicare Extra Help: contact Medicare forinformation on how this program works (seeHelpful Resources)
• State programs: states offer Medicaidinsurance for low-income patients; they alsomay have a state prescription drug program(see Helpful Resources)
• Financial counselors at your treatment center:they can help you get the most out of yourhealth care insurance plan
• Your doctor’s office: ask the billing person ifyou can make payments each month insteadof all at once
• Financial aid: ask employers, labor unions,community service groups, religious groups,or disease support groups for help
What is a Patient Assistance Program (PAP)
• These programs are available to the publicand help patients pay for needed medicines
• These programs are supported bydrug companies
• Help is usually given to people who haveno coverage for medicines and are noteligible for public insurance (Medicareor Medicaid)
Each drug company has specific rules; call them or look online to find out their rules.
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What Should I Ask my Health Care Provider?
• What will be the cost for this treatmentor medicine?
• Is there a less costly medicine I could take?
• Do you know if my insurer pays for thismedicine?
• Who can help me find out if my insurerwill pay for this medicine?
• Do you know of any assistance programthat can help me?
• Can I get this treatment at a lower costif I joined a clinical trial?
• Can the cost of this medicine be adjustedto match my income and other living costs?
• If I must pay for the medicine or treatment,can we work out a payment plan that Ican manage?
Gather this paperwork before you apply for help:
• Bank account statements
• Investment statements
• Tax returns
• Pension letters
• Payroll slips
How Can I Get Help Paying for my Medicines?
Reminder!!
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Frequently Asked Questions (FAQs)
Can I join a Medicare Part D prescription drug plan if I have been treated for my illness under a private insurance plan?
Yes. Medicare Part D does not turn anyone down based on a pre-existing condition.
Most of my medicines are covered under Medicare Part B. If I sign up for Medicare Part D, will that change?
No. Signing up for a Part D plan will not change what Part B pays for. If drugs are given to you by a doctor or nurse in a doctor’s office, clinic, or hospital, they are paid for under Medicare Part B. Part D plans would typically help you pay for oral and self administered medicines.
I am applying for Medicare health and prescription drug insurance. Should I consider calling my prescription drug plan provided by my current or former employer?
No. If you cancel your private drug plan, you may also terminate health coverage for you and family members. Medicare allows you to keep a private insurance plan while also being covered by Medicare. Ask your employer or private insurer about the pros and cons.
If I have a low income, how do I find out about Extra Help under Medicare?
If you need extra help paying for Medicare premiums, annual deductibles, and prescription copayments, stop first at the Medicare website at https://www.medicare.gov/your-medicare-costs/get-help-paying-costs. Here, you can find out if your state offers a Medicare Savings Program or a Program of All-inclusive Care for the Elderly (PACE). You will also find information on Medicaid, which can supplement your Medicare plan if you meet the eligibility rules. To contact a state Medicaid office, a State Health Insurance Assistance Program (SHIP), or find a Medicare Savings Program in your state, see https://www.medicare.gov/contacts/. To apply for the Extra Help program, see the Social Security benefits website at https://www.ssa.gov/benefits/medicare/prescriptionhelp/. These benefits are not retirement or disability programs, but Extra Help.
Frequently Asked Q
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Where can I get help with choosing a plan in the health insurance marketplace?
It’s important that you make the best choice for you. You can enter your own medical and financial information at the secure government website www.healthcare.gov to figure out what plans are available in your state and area, the prices, and the benefits. It may be helpful to ask a social worker or case manager to help you make the best choice for you. The government website can help you find people and organizations in your community that can help you enroll (https://www.healthcare.gov/contact-us/).
How will I know if my prescription medicine is covered in a health insurance marketplace plan?
There are several ways to find out. A potential insurer’s website can provide a list of medicines that would be covered by the plan. Print and read the Summary of Benefits and Coverage which is part of the plan information available with your Marketplace account. Call the insurer directly and ask. Review information sent to you in the mail.
How will I know if Original Medicare or Medicare Advantage is better for me and the medicines I take?
You can get free counseling for your needs by contacting your local State Health Insurance Assistance Program (SHIP) (see Helpful Resources).
Do I need a Medicare supplemental plan?
First, if you have or intend to buy a Medicare Advantage plan, you cannot also buy a supplemental, or Medigap, plan. If you have Original Medicare, and you would like some help deciding, contact your local State Health Insurance Assistance Program (SHIP) (see Helpful Resources).
Do I need a case manager to help me get my medicines and the best health care?
A case manager can be very helpful in assessing your needs. Case managers may work at your physician office or the treatment center or hospital you go to. Seek out their help. Some case managers also work in the community. Look for a case manager who is certified; that is, he or she uses the letters CCM after their name.
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Helpful Resources
Helpful Resources
American Autoimmune & Related Diseases Association
Patient information, advocacy, and resources.
www.AARDA.org
American College of Rheumatology Foundation
Patient information and videos about diseases and education about treatments for arthritis and other disorders.
www.Rheumatology.org
Alliance for Patient Access
Doctors advocating for patient access to care.
www.AllianceforPatientAccess.org
American Diabetes Association
Information and support for patients with diabetes, including meal planning and an online community.
www.Diabetes.org
Arthritis Foundation
Patient education materials, clinical trial information, resource finder.
www.arthritis.org/living-with-arthritis/
Cancer Care
Information, education, counseling, and support for families dealing with cancer.
www.cancercare.org
The Centers for Medicare & Medicaid Services (CMS)
Information on Medicare and Medicaid and the Health Insurance Marketplace.
www.CMS.gov
HealthWell Foundation
Copay, deductible, and health care premium payment assistance for people living with chronic and life-threatening disorders.
www.HealthWellFoundation.org
The Leukemia & Lymphoma Society (LLS)
Support, advocacy, and information for people with blood cancer.
www.LLS.org
Lupus Foundation of America
Education about lupus and information about research.
www.lupus.org
MAGIC Foundation
Support services for families of children with chronic or critical disorders.
www.MagicFoundation.org
Medicaid
Information on government health care for low-income families and individual.
www.medicaid.gov
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Medicare
Information on Medicare plans, forms, applications, and application online.
www.medicare.gov
Multiple Sclerosis Foundation
Education, advocacy, and research news.
www.msfocus.org
National Comprehensive Cancer Network (NCCN) Foundation
Expert information from the world’s leading doctors including guides, videos, help finding a clinical trial, and patient and payment assistance.
www.nccn.org/patients/foundation/default.aspx
National Institute of Neurological Disorders and Stroke (NINDS)
A government web site with clinical trial information and patient support resources for those with disorders of the brain and nervous system.
www.ninds.nih.gov
National Organization for Rare Disorders (NORD)
Resources for people fighting rare diseases.
www.RareDiseases.org
National Psoriasis Foundation
Access to patient navigators who can help you with treatment, financial, and other questions.
www.psoriasis.org
NeedyMeds
Information and direct help for patients seeking medicines they can afford.
www.NeedyMeds.org
Partnership for Prescription Assistance
A free service that connects qualifying patients to prescription drug assistance programs.
www.PPARX.org
Patient Access Network
Help in paying out-of-pocket costs for those with chronic, acute, and rare diseases.
www.PanFoundation.org
Patient Advocate Foundation
Professional case management services for Americans with chronic, life-threatening, and severe diseases.
www.PatientAdvocate.org
Patient Services Incorporated
Financial support and help for patients with specific, rare chronic diseases.
www.patientservicesinc.org
State Health Insurance Assistance Programs
Local help with Medicare plans and Extra Help.
www.shiptacenter.org
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Glossary Term
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Glossary Terms
Affordable Care Act (ACA): a federal law passed in 2010 that provides more options for health care insurance to Americans without coverage or without good coverage, sets essential benefits that health insurers must offer, prevents insurers from denying insurance to or increasing premiums of people with pre-existing conditions, and increases Medicaid coverage
Appeal: a process for asking an insurer to re-review a medical claim that has been denied
Biologics: medicines that are made from living cells and have a complex makeup
Biosimilars: biologic medicines that work the same way a similar biologic medicine works
Brand-name medicines: the name given to a medicine by the company that developed it and requested approval from the Food and Drug Administration
Caps / lifetime limits: a limit to the amount an insurer will pay over the course of a year or an individual’s lifetime. The Affordable Care Act prohibits such limits on plans beginning September 23, 2010 or more recently
Case manager: a nurse or social worker who is trained to advocate for patients, help patients find additional resources like housing, transportation, caregivers, etc. related to medical care
Catastrophic coverage: insurance plans with low premiums and very high deductibles that can be purchased by people younger than 30 or who have a hardship; the current yearly deductible is $7,900
Claim: a request for payment that you or your health care provider submits to a payer when services you’ve paid for or received are eligible for coverage
Coverage: the services that an insurer agrees to pay for (in part or in full) under an insurance plan in exchange for a premium
Coinsurance: a percentage of the cost of a medical service or prescription that an insurer requires individuals to pay after yearly deductibles are paid
Copayment: a special cost that an insurer may require that individuals pay for specific medical services, prescriptions, or equipment
Deductible: a specific dollar amount a health insurance company may require individuals to pay out-of-pocket each year before the company begins to reimburse or pay for medical services and prescriptions
Denial: a refusal by an insurer to pay for a medical service a patient has received
Coverage Gap: Starting in 2020, the coverage gap has been closed, and you generally pay the same amount for your prescription drugs throughout the year
Eligibility: conditions that must be met for an insurer to provide insurance coverage
Essential health benefits: benefits the Affordable Care Act requires insurers to offer, including:
• Ambulatory patient services (outpatient care you get without being admitted to a hospital)
• Emergency services
• Hospitalization (like surgery and overnight stays)
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• Pregnancy, maternity, and newborn care (both before and after birth)
• Mental health and substance use disorder services, including behavioral health treatment (this includes counseling and psychotherapy)
• Prescription drugs
• Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)
• Laboratory services
• Preventive and wellness services and chronic disease management
• Pediatric services, including oral and vision care (but adult dental and vision coverage aren’t essential health benefits
Explanation of Benefits (EOB): a letter from an insurer that tell a plan member what has been paid for a medical service
Exclusive Provider Organization (EPO): a type of insurance plan that pays for services provided by in-network providers and does not cover costs of seeing providers out-of-network; you do not need to choose a primary care provider
Extra Help (Low-income Subsidy): a Medicare program to help people with limited income and resources pay Medicare prescription medicine costs, including premiums, deductibles, and coinsurance
Fee-for-Service (FFS): insurance plans that allow you to choose your own doctors and other health care providers; reimbursement is paid at a set amount by the insurer and those who are part of the plan usually pay a deductible and copayments or coinsurance
Formulary: a list of drugs that an insurer will cover
Generics: a medicine that is the same as a brand-name drug but does not have a brand-name
Health Care Exchanges (Health Insurance Marketplace): a service available in every state that helps individuals, families, and small businesses shop for and enroll in affordable medical insurance plans
Health Maintenance Organization (HMO): a type of insurance plan that offers services through a network of providers who have agreed to charge a certain fee; plan members are required to choose a primary care provider who will manage their care
High-Deductible Health Plan (HDHP): a type of insurance plan that requires those in the plan to pay much more in out-of-pocket spending for lower premiums
Infusion pump: a medical device that delivers fluids, including medicines, into a patient’s body
In-network providers: health care providers who have contracted with an insurer to provide care for patients covered by the plan at a certain price
Insurer (Payer): an insurance company, employer, or government who contracts with people to provide insurance
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Managed care: a general term to describe health insurance plans that guide patient’s use of benefits, usually by requiring patients to see a primary care provider first or by creating a network of providers
Medicaid: health insurance that each state offers to needy individuals and families
Medicare: health insurance the US government offers to people who are 65 and older and to some people who have certain disabilities
Medicare Advantage: health insurance plans sold by private companies who have been approved by Medicare to sell Parts A and B coverage and allow you to purchase drug coverage
Nebulizer: a medical device that turn liquid medicine into a mist that can be breathed in
Open enrollment: a time of year when you are able to sign up for coverage under an employer’s or government health plan; for Medicare plans, the dates are November 1 to December 15 of each year
Out-of-network providers: health care providers who have not signed a contract with an insurer to offer services to plan members at a discounted rate
Out-of-pocket (OOP): costs a health plan member must pay each year that are not covered by an insurer
Patient Assistance Programs (PAPs): programs that provide help to patients who cannot afford their medicines and have no form of prescription drug coverage Patient’s Bill of Rights:
a list of guarantees for those receiving medical care; under the ACA, this means insurers cannot deny coverage to people with pre-existing conditions and cannot place caps or lifetime limits on costs for health problems that a person already has
Point of Service (POS): insurance plans that may require members to choose a primary care provider to manage referrals to specialists in the plan’s network; costs charged by providers out-of-network may not be paid
Pre-existing conditions: health problems that existed or were treated before the date a health plan began coverage
Preferred: medicines that are included in an insurer’s formulary
Preferred Provider Organization (PPO): an insurer that requires those in the plan to use its list of providers in exchange for the highest reimbursement amount; services by providers outside the preferred network may not be paid for or may be paid at a much lower rate
Premium: the payment to an insurer, health care plan, or government that buys insurance coverage
Prescription: medicine that requires a doctor’s written note to buy and that has been approved by the Food and Drug Administration
Prescription Drug Plans (PDPs): Medicare drug plans that pays for part of prescription medicine costs; optional Medicare coverage you can purchase
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Glossary Term
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Preventive health care: health care that focuses on preventing illness or detecting it at a very early stage when treatment works best; services include:
• Screenings for children for autism, development, behavior; newborn screening; vaccinations; and more
• Screenings for adults: blood pressure, cholesterol, some cancers (colon, lung), some types of hepatitis (B and C), HIV, depression, diabetes, abdominal aneurysm, cigarette use and alcohol abuse, tuberculosis, obesity; others for women; vaccinations; counseling for many problems; falls prevention
Provider networks: a group of doctors or hospitals who contract with an insurer to provide health care services to members of a health care plan
Referrals: a process in which a primary care provider gives a plan member the ability to see a specialist for a specific condition
Special enrollment: times of year other than open enrollment when you may purchase health insurance because you have had a life-changing event such as:
• Marriage or divorce
• Childbirth
• Independence from parents
• Loss of employer insurance
• Death of primary insured
• A move to a new area (change of zip code)
• Change in income
• Denial of Medicaid
• New citizenship or legal status
• Release from jail
• Recognized by US government as an American Indian or Alaska Native
Specialty medicines: medicines that are high cost and require a health care provider to give to patients
Social Security Disability Insurance (SSDI): a US government plan that provides assistance to people with disabilities
Supplemental Security Income (SSI): a US government program that provides cash assistance and health care coverage to people in need
Supplemental coverage (Medigap): extra insurance a person can buy to help pay for services and out-of-pocket expenses not covered by Medicare; people with Original Medicare may buy this coverage
Tax credits: credits provided to needy Americans by the US government to help them pay their premiums if they buy a health care insurance plan through the Health Insurance Marketplace
Tiers: group of medicines that have a different cost for each group
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My Im
portant Contacts and Health Insurance Inform
ation
My Important Contacts and Health Insurance Information
Primary Care Physician: _________________________________________________________________
Telephone #: _______________________________________________________________________________________
Office address: _____________________________________________________________________________________
Physician (specialty): ____________________________________________________________________
Telephone #: _______________________________________________________________________________________
Office address: _____________________________________________________________________________________
Physician (specialty): ____________________________________________________________________
Telephone #: _______________________________________________________________________________________
Office address: _____________________________________________________________________________________
Insurance Provider: _____________________________________________________________________
Name of Plan: ______________________________________________________________________________________
Member Number: __________________________________________________________________________________
Group Number: ____________________________________________________________________________________
Policy Number: _____________________________________________________________________________________
Telephone #: _______________________________________________________________________________________
Points to Remember• Talk to your health care provider right away if you have questions about your insurance
and what it covers. Most offices have someone to help you with this.
• Request a case manager from your insurance company to help you understand your insurance plan and get information about your claims.
• Keep good records of each time you call or see a health care provider or an insurance company. Be sure to write down the person’s name and date of the conversation. These notes will be important if you need to file an appeal.
• Don’t be afraid to appeal if your insurance company denies your claim because this is your right and is also common.
• Seek help if you have trouble paying your bills. Counselors, case managers, and others can help you find patient advocacy groups that may be able to help. See the Helpful Resources for some of these groups.
©2020 Cephalon, Inc., a wholly owned subsidiary of Teva Pharmaceutical Industries Ltd. NPS-40312 June 2020
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