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Insurance 101

A GUIDE TO NAVIGATING PLANS AND COVERAGE OPTIONS


Health insurance can be complex—we get it. It’s important to learn about the options available so that you can make a decision that’s right for you.

Note: Eligibility for insurance plans is varied. You may not be eligible for every insurance plan mentioned in this guide.

Commercial Insurance Government-Funded Insurance Choosing a New Plan Glossary of Terms

UNDERSTANDING HEALTH INSURANCE


There are 2 categories of health insurance: commercial and government-funded. Here’s a closer look at each type.

COMMERCIAL

 

There are 2 types of commercial plans: group plans and individual plans.

GROUP PLANS

Got a full-time job?

Your employer might offer a group plan.

A group plan is coverage provided by an employer or
employee organization.
You may be familiar with some commercial health
insurance companies. Some examples are Aetna,
BlueCross BlueShield, and UnitedHealthcare.

  • Remember: If you are 26 years old or younger,
    it may be possible to be included on a group
    policy from your parent or guardian's employer

INDIVIDUAL PLANS

Not able to access a group plan?

You can still buy health insurance on your own.

With individual plans, you purchase coverage directly from a private insurer or through the Health Insurance Marketplace (sometimes called the Health Insurance Exchange).

The Marketplace, created as part of the Affordable Care Act, provides coverage to people who don't have access to a group-based plan, and don't qualify for Medicare or Medicaid.

For more information about Marketplace plans, visit www.HealthCare.gov.

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Before you purchase an individual plan, check to see if you qualify for Medicaid or even Medicare. 

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Choosing a new insurance plan? Here’s what you need to consider.
You may want to call each insurance company to find out:

  • Does the plan cover your preferred doctors, specialists, pharmacies, and emergency care and hospital admissions?
  • Are your prescriptions covered by the plan? (eg, on formulary or not, requires co-payment, goes toward the deductible)
  • Does the plan cover generic and brand drugs?
  • Are any prior authorizations required?
  • What are the out-of-pocket costs, deductibles, and
    premiums?
  • Ways you can reach a representative from a company to determine how easy they will be to contact.

    GOVERNMENT-FUNDED

     

    There are 2 major types of government-funded healthcare: Medicaid and Medicare.

    MEDICAID

    Do you have limited income or resources?

    Then Medicaid may be the right option for you.

    Medicaid is a joint federal and state program that helps with medical costs for some low-income adults, children, pregnant women, elderly people, and people with disabilities. It covers:

    • Free or low-cost healthcare for low-income individuals who qualify
    • Inpatient and outpatient hospital services, doctor visits, nursing home and home health services, and lab and X-ray services

    Be sure to check your state’s eligibility guidelines for Medicaid before purchasing an individual plan.

    Keep in mind that Medicaid coverage and eligibility vary from state to state, and some states may place limits on medications. Visit www.Medicaid.gov to find out more detailed information about Medicaid and your eligibility.

    MEDICARE

    You may also qualify for
    Medicare.

    Medicare is the federal health insurance program not just for people who are 65 years old or older, but also for certain younger people with disabilities and people with end-stage renal disease.

    For more detailed information about Medicare coverage, visit www.Medicare.gov.

    .

    Remember that there may still be out-of-pocket costs for those on government-funded insurance plans like Medicare and Medicaid. Also, starting or renewing coverage of any kind can affect out-of-pocket costs. Keep in mind that some plans have limits on out-of-pocket expenses.

    .

    DUAL ELIGIBILITY

    People who are dual-eligible are enrolled in both Medicare
    and Medicaid at the same time. Dual eligibility allows for more
    comprehensive coverage and typically applies to those with
    significant medical needs.

    Medicaid does not pay for services covered under Medicare.
    Medicaid coverage only goes into effect after Medicare,
    employer plans, or Medigap plans have been applied.

    INSURANCE EVALUATION WORKSHEET

    This worksheet can help you evaluate health plans and some of their benefits. Be sure to factor in any other costs you may have. Download here.

    Updating your insurance policy

    .

    Here’s what to do after you change your plan:

    • Get to know your insurance card. You will need to provide your new information to your care team. They may ask for your:

    MEMBER ID NUMBER
    This number is unique to you. It identifies you as an individual who is covered and allows you to access your benefits when you need care.

    GROUP NUMBER
    If you received insurance through an employer, a group number will also be listed on your card. This helps identify the benefits you receive through your employer’s plan. Your care team may use this number to file claims.

    • Update your healthcare provider. Once you’ve changed insurance policies, let your cystic fibrosis (CF) Care Center and other members of your healthcare team know about your switch.

    • Coordinate with your specialty pharmacy. Make sure they are aware of your new insurance plan and any coverage changes as soon as possible.

    Coverage loss related to employment 

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    If you lose your employer-based coverage, you may have the following options:

    Special enrollment period: During this time, you can enroll in an individual plan by purchasing it directly from the Health Insurance Marketplace. You usually have 60 days from the day you lose coverage to enroll.

    COBRA (Consolidated Omnibus Budget Reconciliation Act): With COBRA, you have the option to continue the coverage you received from your former employer for a limited period of time.

    Medicare and Medicaid: If you qualify for government-funded insurance, you can enroll in these programs at any time.

    Glossary of insurance terms

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    Here are some terms you may have seen in this resource or during your own research into healthcare coverage.

    CLAIM

    A request for payment from your health insurance company after you receive a medical bill. Claims can be submitted by you or your healthcare provider for covered services.

    COBRA

    The Consolidated Omnibus Budget Reconciliation Act (COBRA) gives individuals and families the right to continue receiving health insurance coverage after a loss of group plan benefits. This can be due to voluntary or involuntary job loss, reduction in the hours worked, transition between jobs, death, divorce, and other life events. If you qualify, you may be required to pay the entire premium for coverage up to 102% of the cost to the plan.

    CO-PAY ACCUMULATOR

    A policy in which manufacturer coupons do not count toward your deductible. This includes co-pay assistance programs, co-pay cards, and traditional coupons.

     

     

    HOW DOES IT WORK? In the past, some health insurance plans allowed members to count the total assistance received from co-pay assistance programs toward an annual deductible and out-of-pocket maximum. With co-pay accumulator programs, that assistance will no longer “accumulate” toward your deductible and out-of-pocket maximum.

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    COORDINATION OF BENEFITS

    Sometimes 2 insurance plans work together to pay claims for the same person. That  process is called coordination of benefits. Insurance companies coordinate benefits to
    avoid duplicate payments, to establish which plan is primary and which plan is secondary,
    and to help reduce the cost of insurance premiums.

    DEDUCTIBLE

    The amount you may have to pay for care or prescriptions before your insurance kicks in.
     

     

    HOW DOES IT WORK? You see an out-of-network specialist twice a month for $100 a session. Your out-of-network deductible is $1,000. You will pay $100 for the first 10 sessions—until you reach $1,000. After you meet the $1,000 deductible, your specialist visits will be covered by your plan for the remaining calendar year. Note: You may still be responsible for a co-pay after your deductible is met.

    .

    DRUG FORMULARY

    The list of all prescription medications that your plan covers.
     

    EXCLUSION OR LIMITATION

    This refers to a specific drug, surgery type, act, or condition that your health insurance policy will not cover.
     

    EXCLUSIVE PROVIDER ORGANIZATION (EPO)

    Type of plan that covers services only when you use doctors, specialists, or hospitals within the plan’s network. Note: Be sure to confirm your cystic fibrosis (CF) Care Center is in network before enrolling in an EPO plan.
     

    EXPLANATION OF BENEFITS

    A report or statement you receive from your insurance company that explains how they paid your claim, according to the benefits described in your health plan.
     

    FORMULARY

    The list of all prescription medications that your plan covers. A formulary can be:

    • Open: little or no limitation on the medications covered
    • Restricted: some flexibility in choice of medication
    • Closed: coverage limited to only the medications specified in the formulary


    HEALTH INSURANCE NETWORK

    The collection of doctors, suppliers, and facilities that your health insurance plan has under contract to provide your healthcare services.
     

    HEALTH MAINTENANCE ORGANIZATION (HMO)

    This type of plan usually limits coverage to care from doctors who work with the HMO. It generally won’t cover out-of-network care except in an emergency, and it may require you to work or live in its service area to be eligible for coverage.
     

    IN-NETWORK CO-PAY/CO-INSURANCE

    A fixed amount you pay for covered healthcare services to providers who contract with your health insurance or plan. This amount is usually less than the cost of an out‑of‑network co-pay/co-insurance.

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    HOW DOES IT WORK? Let’s say your doctor bills you $100, and your health plan’s co-pay or co-insurance amount is 20%. You would pay 20% of the total bill ($20), and your health insurance plan would pay the remaining 80% ($80) once any deductible is met.

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    IN-NETWORK PROVIDER

    A doctor who is contracted with the health insurance plan to provide services to policyholders for specific pre-negotiated rates.
     

    MANAGED CARE

    A healthcare plan or system that aims to control medical costs by contracting with a network of providers.
     

    OPEN ENROLLMENT

    The yearly period when you can enroll in a health insurance plan.
     

    OUT-OF-NETWORK CO-PAY/CO-INSURANCE

    A fixed amount/percentage you pay for covered healthcare services to providers who do not contract with your health insurance plan. This amount is usually more than the cost of an in-network co-pay/co-insurance.
     

    OUT-OF-NETWORK PROVIDER

    A doctor who is not under contract with your health insurance plan. When you get care from an out-of-network provider, your insurance company typically pays either less or nothing at all for the services you received.
     

    OUT-OF-POCKET LIMIT

    The most you pay during a policy period (usually per year) before your health insurance plan begins to pay 100% of the allowed amount.
     

    PHARMACY BENEFITS MANAGER (PBM)

    A third party who works on behalf of a health plan to help with the processing and paying of claims. They act as a coordinator between insurance companies, drug manufacturers, pharmacies, and insurance policyholders. They also offer programs to participants that provide services such as assistance with mail-order pharmacies and disease management initiatives.

    PREFERRED PROVIDER ORGANIZATION (PPO)

    A type of healthcare plan that allows you to use doctors both inside and outside of your network and get coverage for both, but you pay less for care from in-network providers.
     

    PREMIUM

    The monthly amount that must be paid for your health insurance or plan to keep your coverage active.
     

    PRIOR AUTHORIZATION

    A prior authorization, or PA, may be a requirement of your insurance company before you can receive your medicine or other procedures. If required, your doctor works with your pharmacy to provide this information. Also, it’s important to keep in mind that a PA may need to be renewed after a certain amount of time.
     

    It may help to keep an updated list of your medications that require a PA so you know when renewals are needed.

    REIMBURSEMENT

    The system through which the insurer pays doctors for healthcare services.
     

    SPECIAL ENROLLMENT PERIOD

    Time frame outside the open enrollment period when you can still sign up for health insurance. You qualify for this enrollment if you’ve had certain life events or unusual circumstances, and you usually have up to 60 days following the event to enroll in a plan.

     

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