Insurance Q&A

If you are newly enrolled in Medicare, you are guaranteed the ability to purchase a Medigap policy. During this open enrollment period, there is no medical underwriting. To find policies sold in your area visit www.medicare.gov. Click on “search tools” and then on “compare health plans in your area.”

To help with your decision making, the Department of Health and Human Services offers a guide to Choosing a Medigap Policy (PDF).

Depending on which state you reside in, there have been some legislative changes that impact the age category your daughter falls into. About one half of the states have enacted legislation that expands dependent coverage up to, in some cases, 30 years of age. Requirements vary by state, but most only require that the dependent be unmarried. The Kaiser Family Foundation State Health Facts website offers a page that lists definition of dependency by age if you would like to research the requirements in your state.

Other options that you may have are dependent on whether your daughter is considered disabled. A disabled dependent can have special status on your insurance policy. I recommend that you contact the PSI ACCESS Program at 1-888-700-7010. This group provides help for primary immune deficient patients in need of assistance with Social Disability information.

This can be an overwhelming task. Our recommendation is that you use a binder system that has pocket folders inside to organize and keep track of your paperwork.

It is important to review each Explanation of Benefits (EOB) that comes to you from your insurer and match the EOB with each associated provider statement or bill. It is good to staple or paperclip these together. Insurers can make errors, so it’s important to assure that in-network benefits are paid appropriately. You will also need to assure the amount you are being charged by the provider is the amount that your insurer has designated as your responsibility.

It is tough being in the job market these days. Trying to find a large group employer may be asking a lot, but this is his best option. Additionally, in some states, the dependent age status has been increased. We need to check your state laws, because he may be eligible to keep his current insurance until he has a job that provides insurance.

There are a number of issues here. Most insurers are not going to want to sell a private plan to you due to your wife’s illness and her cost of care. If you do find a plan, the cost will be extraordinarily expensive. If you have insurance for her, please stick with it. Depending on the work you do, there may be group health insurance options. Also, in most states there are high risk insurance pools that she can buy into.

Most insurers authorize treatment up to one year and then require the provider of services to reapply for the authorization. They are not denying treatment, but are trying to assure that the treatment continues to be appropriate. While IVIG is appropriate for a lifetime for some people with an immune deficiency, there are other uses of IVIG that do need to be reviewed at least annually.

There are definitely benefits to each plan individually. HMO plans are more restrictive. Some of your preferred physicians, as well as your pharmacy, may not be in the network. HMOs also require a referral to specialists by the primary care physician. HMOs do have, in general, less out-of-pocket expenses.

PPO plans give you a choice of physicians and pharmacies without a referral. PPO plans also have deductible and out-of-pocket expenses until you have reached a maximum, at which time the benefit level converts to 100% in most cases.

HSAs, or Health Savings Accounts, are not good for persons with a chronic illness. These plans are geared toward very healthy individuals that can pay out general claims from a savings account.

Each insurance company has different requirements. Most do require a prior authorization or pre-approval. Your provider of IVIG will obtain this approval for you by submitting a statement from your physician.

Insurance denials are not uncommon, even when you have been receiving therapy continuously for a number of years. It is important to seek assistance from your physician, your provider of therapy, the manufacturer, and the Immune Deficiency Foundation to file an appeal. Most insurance companies do not understand your illness like you and your physician do. The physician or your provider can assist you in filing an appeal. Information that needs to be included in your appeal would include your laboratory results, relevant medical articles as well as the symptoms you develop when you are without treatment. Your physician will be experienced in the information needed by the insurance. There are additional appeal processes that are available if needed.

Most insurance will pay for the supplies and nursing services associated with infusion therapies. Medicare is the exception to this.

While the diagnosis of CVID alone is not a sufficient qualification for disability, your medical situation may qualify you for disability payments. I recommend you contact the ACCESS (Advocating for Chronic Conditions, Entitlements, and Social Services) program. This nonprofit program will assist patients with Primary Immune Deficiencies in seeking disability qualification. The phone number is 1-888-700-7010.

The good news is that as long as you have had creditable coverage there should be no pre-existing condition clause imposed on your new policy. As with any new coverage, you should make sure your physician and provider are in your network. Look at the out-of-pocket expenses associated with any new insurance option, as some plans may have large deductibles and co-payments. Check to see if there is a waiting period before you are eligible for insurance benefits. If you are subject to a long waiting period, you may need to select COBRA coverage from your previous employer during this time.

There may be options for you, but additional information is needed before any suggestions could be made. For example, where are you currently receiving your therapy? Have you applied for Medicaid and/or Disability? What state do you live in?

Your insurance policy should be evaluated to determine what your true deductibles and out-of-pocket expenses should be. Many insurance plans have an annual maximum out-of-pocket expense limit, after which claims are paid at 100 percent. You may also want to evaluate your options during your employer’s open enrollment period to determine if, by paying a few additional dollars per month for another plan, your out-of-pocket expenses could be reduced. Of course, you will want to make certain that your physicians, providers and medications are covered.

There are many different reasons why claims are denied. The first step is to identify the reason for the denial. Often, the cause could be something relatively simple that a phone call to the insurance company would resolve. Other claim denials may be more complicated. Please remember it is ultimately your responsibility to make sure your provider receives payment for all the services provided to you.