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Before you ask, see answers to popular questions about coverage for PI treatment.

Question: Why do I need to be concerned about my insurance coverage?

Answer: People with primary immunodeficiency (PI) 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 selection of an appropriate insurance plan can affect the health and finances of both the patient with PI and family members. 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.

Question: What difference does it make which type of coverage I choose?

Answer: When you are selecting insurance coverage, you may have a choice between a traditional fee-for-service policy and more restrictive Health Maintenance Organization (HMO), Point of Service (POS), or Preferred Provider Organization (PPO) coverage. The choice depends on how much freedom you want in selecting your doctor versus 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 allow you the latitude to choose the medical 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, but you will most likely face higher deductibles and out-of-pocket expenses.

Question: What questions should I ask when I'm looking for insurance coverage?

Answer: You should ask whether your policy covers visits to your current physician, and you should find out if there are any hospitals that 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.

You should also ask whether a particular treatment is covered, and of those costs, which are covered by the policy and which are covered by the patient.

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 your treatment or clinic visits (or any other type of medical services). It is very important that you determine if your insurance has a lifetime maximum.

Question: How can I find out if a specific treatment was covered?

Answer: 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 IgG product shipments and the administration of your therapy. If you don't receive an EOB, request a copy through the insurance company or your IgG provider (physician, distributor, or home care company).


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