Open Enrollment Season is approaching again!
There are a few questions you need to ask when choosing an insurance plan if you or a family member have a bleeding disorder diagnosis.
How do you get your insurance?
Do you get your insurance from an employer sponsored plan, through the ACA marketplace, or through a public payer such as Medicare or Medicaid? Where your insurance comes from will determine the laws that govern coverage requirements.
Is your preferred pharmacy in network (including your HTC’s Pharmacy)?
Even if your healthcare providers are in-network, your preferred pharmacies often aren’t. As insurance companies increasingly acquire pharmacies, they usually limit patients to a smaller network, which can delay care for urgent needs like clotting factor.
Are yours/your family members medications covered?
To combat rising drug costs, many self-funded employer plans use alternative funding methods that exclude coverage for specialty drugs. Patients must then grant power of attorney to a broker and provide financial documents for enrollment in a manufacturer’s charity program, designed for those without insurance or a gap in coverage. These programs offer limited, short-term assistance and are not suitable for urgent situations, often taking 3-5 business days to deliver medication. This can result in complications like joint damage or lead patients to seek emergency care for their meds. Moreover, these charity programs are not intended for long-term use and often fail to provide sustainable solutions, leaving patients vulnerable to ongoing gaps in care and persistent financial burdens.
Does manufacturer copay assistance count toward your deductible or max out of pocket?
Manufacturers provide copay assistance cards to help patients afford medications. While these rarely lead patients to choose more expensive options for bleeding disorders, they sometimes do when cheaper generics are available. To counter this, insurance companies use copay accumulator adjusters, allowing patients to use assistance until it runs out, but resetting the deductible so that those funds don’t count. After the assistance is gone, patients must meet the full deductible to receive coverage, making access to costly biologics difficult. Copay maximizers use a loophole in the Affordable Care Act (ACA) to classify certain drugs as non-essential benefits, setting separate deductibles based on the available assistance. This allows access to medication, but the assistance does not count toward the overall deductible, leaving patients responsible for those costs before receiving coverage for essential benefits.
Ensure you have appropriate coverage (If health insurance is obtained via the marketplace)
Many of the advertised “low-cost” plans may not provide the necessary benefits and could result in significant out-of-pocket expenses. To ensure you receive adequate coverage, consider selecting plans that comply with ACA standards.
REMEMBER…
While HOC cannot make the decision for you, we are dedicated to providing you with the education and resources you need to choose the best plan for your unique needs. It’s crucial to keep HOC informed about any changes to your insurance so we can ensure there are no gaps in your treatment plan or that of your family members. Your well-being is our top priority, and we’re here to support you every step of the way!
