Therapeutic Play Kit
Find information onCommon Insurance Questions
Q: Why do I need to be concerned about my insurance coverage?
People with immune deficiencies and their families often experience numerous medical bills. It is important to fully understand your insurance benefits and the types of coverage your policy will provide. The healthcare landscape is changing rapidly, mergers and acquisitions between insurance companies and those companies that provide intravenous immune globulin (IVIG) products continue to take place. Taking the time to ensure that you have asked all of the right questions prior to choosing a health insurance plan will help avoid problems with your family's coverage and financial responsibilities down the road.
If you have questions about insurance coverage, you can get assistance by calling Baxter's GARDian program at 1-877-655-GARD (4273) or visit myGARDian.com.
Q: When can I make changes to my insurance coverage?
People covered by an employee-based insurance plan usually make decisions about their coverage for the upcoming year during an open-enrollment period. Many times these decisions need to be made at the end of the year, often occurring in October or November, since many policies become effective at the beginning of the following year.
It is very important that families dealing with immune deficiencies know when their open enrollment period is and the options that their employer offers. You should also check to see whether your current plan has changed or your employer is offering new types of plans.
Depending on which type of plan you decide to choose (PPO, POS, HMO), make sure that you verify either through your employer or directly with the insurance company if your provider of IVIG is in-network or out-of-network. The difference between the two can have major coverage and financial implications for you and your family.
Q: What difference does it make which type of coverage I choose?
When you are selecting insurance coverage, you may have a choice between a traditional fee-for-service policy and more restrictive HMO, POS or PPO coverage. The choice depends on how much freedom you want in selecting your doctor and the cost savings you want to experience in having a more limited choice. The choice may come down to whether or not your physician is part of the plan. Traditional fee-for-service plans (Indemnity Insurance) often allows you the latitude to choose the physician and IVIG provider of your choice. However, choosing the more typical managed care type plans will often restrict the ability to make these decisions. The most popular types of managed care plans are HMOs, POS and PPOs. HMO plans are usually the most restrictive when it comes to choosing your network of providers. PPO and POS plans may allow you to choose providers outside of the contracted network of providers, but you will most likely face higher deductibles and out-of-pocket expenses.
Q: What is an HMO?
A Health Maintenance Organization (HMO) is an organization of healthcare personnel and facilities that provides a comprehensive range of health services to an enrolled population for a fixed sum of money paid in advance for a specified period of time. These health services include a wide variety of medical treatments and consults, inpatient and outpatient hospitalization, home health service, ambulance service, and sometimes dental and pharmacy services. HMO plans also monitor the need for an individual to see a specialist, such as an immunologist. Most likely you will have to obtain a referral from your insurance company to see the specialist. Primary Care Physician's (PCPs) are the "gate-keepers" for the HMO, and are responsible for verifying the need of an individual to see a specialist. Often these PCPs are general practionors or internal medical physician's who may not fully understand you or your family's immune deficiency. Be careful to choose a PCP that fully understands your medical needs, and for whom you feel most comfortable dealing with. After all, the PCP is responsible for the continuity of care you and your family receive while with the HMO.
Q: What is a PPO?
A Preferred Provider Organization (PPO) is a group of physicians and/or hospitals who contract with an employer to provide services to their employees. In a PPO, the patient may go to the physician of his/her choice even if that physician does not participate in the PPO, but the patient may have to pay higher out of pocket and deductible costs when doing do so.
Q: What is a POS plan?
POS means Point of Service. It is a plan that offers a transition product incorporating features of both HMOs and PPOs. Beneficiaries are enrolled in an HMO but have the option to go outside the network at an additional cost.
Q: What are Consumer-Driven Healthcare Plans?
As healthcare costs continue to rise, employers offering health benefits to their employees are looking at new ways to save the company money as it pertains to overall health insurance coverage. One trend that has gained some momentum with employers is the idea of Consumer-Driven Healthcare Plans (CDHPs). The main drive behind CDHPs is to cut costs by allowing employees to take control of their own healthcare. Employees are given incentives if they allocate their medical dollars wisely. The most familiar type of CDHP is the medical flexible spending account (FSA), which shelters employer and employee contributions for healthcare expenses from taxes. The only problem is that FSAs are "use it or lose it," type plans. meaning that funds set aside for healthcare expenses incurred in a given year are forfeited if they are not spent by the end of the year. Another form of CDHP is the Health Savings Account (HSA), which was introduced into the market place in 2004. HSAs offer a route to relatively affordable premiums and tax advantages in exchange for high deductibles. The law requires HSAs be established in conjunction with a policy carrying an annual deductible of $1,000 for individuals or $2,000 for families. Like FSAs, HSAs are a means of accumulating tax-advantaged money that can pay for healthcare expenses (uncovered doctor visits, co-pays, premiums, etc.). They are distinct from health insurance, but must be used in conjunction with it. Unlike FSAs, HSA contributions can be carried over to the next year.
Individuals with chronic disorders must be aware of the downside to these types of consumer-driven healthcare plans. Employers benefit by enticing employees to buy into high-deductible policies which may only help a narrow slice of employees. This narrow slice of employees would be those who are young, healthy and financially able to risk a spike in costs due to unanticipated medical expenses.
Q: What are co-payments?
Co-payments are a sum of money that you will pay each time you receive a service or product from a healthcare provider. For example, you might visit your physician and pay a $15 co-payment for the visit. Your insurance company will pay the balance. Check on the amount of co-payments and deductibles you will have to pay.
Q: What is a deductible?
Your deductible is the total amount of money you will need to pay before your insurance plan begins paying its share of costs. For example, you may have a $250 deductible for hospitalization. You are obligated to pay the first $250 before your insurance company will pay additional amounts.
Q: What questions should I ask when I'm looking for insurance coverage?
You should ask whether your policy covers visits to your current physician and you should find out if there are any hospitals which the policy does not include. Some policies will restrict the number of hospitals at which you can receive coverage. It is vitally important that you research this restriction thoroughly before you make an insurance selection. Check with your insurance company, employer's benefit administrator or physician's office for additional information.
It is also important to ask whether a policy has a lifetime maximum on benefits. A lifetime maximum represents the maximum amount of costs that your insurance will cover during your lifetime. If the maximum is exceeded, your insurance may no longer pay for IVIG or clinic visits (or any other type of medical services). It is very important that you determine if your insurance has a lifetime maximum.
Whether and how IVIG is reimbursed by the insurance company is yet another important consideration. Certain policies may not pay for or have restrictions on IVIG. Some policies will pay for IVIG under the pharmacy benefit, so you are only obligated to pay a co-payment each time you receive IVIG. Other policies may cover IVIG under the major medical (hospital) benefit. In this case, you may have to pay a deductible as well as a percentage of the overall cost.
For a downloadable list of key questions to ask your insurer, visit myGARDian.com.
Q: How can I find out if a specific treatment was covered?
After you or your doctor sends a claim to the provider, you should receive an Explanation of Benefits (EOB). The EOB will summarize and explain the amounts approved and paid to healthcare providers. It will also explain why certain services were not covered or paid for. Make sure you thoroughly read your EOBs to ensure proper charges, deductibles, and other out of pocket charges have been calculated correctly. Your EOB will also help you keep track of where you are against any lifetime cap that you may have. An EOB is generated every time you receive services through the health plan, including your IVIG product shipments and the administration of your therapy. If you don't receive an EOB, request a copy through the insurance company or your IVIG provider (physician, distributor, or home care company).
Q: What is a "transition of care" benefit?
Some employers will offer a "transition of care" benefit, which allows you to continue seeing a physician for a diagnosis even after your plan changes. For example, if your current plan allows you to see your primary physician and you transition to a new plan to which your current physician does not belong, your company may have included a "transition of care" benefit that allows you to be covered for seeing your physician for a specific amount of time.
Q: What are referrals?
Referrals are a form of authorization by your managed care plan or primary care physician. Some insurance policies may require referrals for additional treatment and coverage. Ask the insurance provider whether clinic visits, laboratory analyses, or home infusion of IVIG require a referral.
Q: Can I be covered by more than one insurance plan?
Yes. Other family members may have insurance plans offering additional coverage for which you may be eligible. Some healthcare providers will bill a secondary insurer, while others will not. Look at the EOB to determine whether the other insurer has been billed. If it has not, call the primary insurance plan and update them.
Q: What can I do if I am denied coverage for my PI treatments?
If your therapy is denied coverage, contact your local physician or IVIG provider. Request reconsideration and possibly file a formal appeal. Make sure you truly understand the reason for the denial. If you do not feel the denial is justified, contact your insurer's Patient Services Coordinator. You may need to follow up this request with a reconsideration letter. Your physician office and IVIG distributor can assist you in this process.
If you are a GAMMAGARD therapy patient, Baxter's GARDian program can also assist you with coverage appeals. To learn more, call 1-877-655-GARD (4273) or visit myGARDian.com.
Q: What else should I remember when dealing with insurance?
Always remember that you need to be an advocate for your insurance coverage. This is why you must fully understand your insurance policy and the resources available to assist you. Also remember, you're not alone when having to deal with adverse situations when it comes to your insurance coverage. Many IVIG manufacturers offer assistance programs and help is always available through your State's Insurance Department.
If you are a GAMMAGARD therapy patient, Baxter's GARDian program can help you with your insurance challenges and questions. To learn more, call 1-877-655-GARD (4273) or visit myGARDian.com.
