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Learn About Private Health Insurance 

 
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Stay Tuned

The 2010 federal health care legislation has some reforms for adults with CF. Adults may now remain on their parents’ insurance until age 26.

In 2014, other reforms will start, including:

Insurance plans must offer coverage to adults with pre-existing conditions like CF.
•  Insurers cannot restrict your coverage or base your premiums on health status.
•  Insurers cannot impose annual dollar limits to your benefits.
•  States can expand Medicaid to adults who meet a specific income limit.

If your plan was issued before March 23, 2010, these reforms may not apply. Contact your insurance company for information about your plan.

 
When to Buy Health Insurance    

When you approach 18 years of age, you can begin to think about voting, buying a car and getting your own place to live! You should also think about buying your own health insurance.

If you are between 18 and 26 and are covered by your parent’s health insurance policy and they agree to continue covering you, you can remain on it until your 26th birthday.

If you are older, you can buy your own policy through a large company by paying a certain amount of money a month, called a premium. The premium cost is determined by the amount of coverage that you purchase.

Many people have health insurance through an employer-sponsored plan. People with CF can get health insurance through employer-based plans. Under the Health Insurance Portability and Accountability Act (HIPAA) an employee cannot be excluded from coverage due to his or her health.

If you turn 26 and will not be covered by your parents’ health insurance, you will need to get health insurance.

Remember: it is easier for you to maintain health insurance coverage than to have it and lose it and then try to sign up for it again. 

If you lose your insurance and are not covered by an insurance plan for more than 63 days, you may have to pay for your CF clinic visits or medicines.

Some insurance companies will have a pre-existing condition clause. This means that you will have to wait a period of time, but no longer than 12 months, before the insurance company will pay for your CF doctor visits or medicines. 

What Your Insurance Needs to Cover 

For an adult with cystic fibrosis, the three areas of coverage that you absolutely should have are: 

  • Hospitalization
  • Prescriptions
  • Durable medical equipment (also called DME), e.g., nebulizers and airway clearance devices

You can buy more coverage, like dental and vision, if you wish. Even after you choose coverage and agree to premium costs, few health insurance policies cover pay 100 percent of costs, so you will be asked to pay for some things out of pocket, for example co-pays and deductibles.

Premiums, Co-pays, Co-insurance and Deductibles 
  • Premiums - The amount you pay each month to have health insurance coverage.

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    Understanding Your Insurance Premiums

    When exploring health insurance plans, these are the things to compare.

    For example, you may have to pay a higher premium to get a lower deductible but it could ultimately save you money.

    The example below may help explain this. These amounts are for demonstration only and are not actual numbers.

    Let’s say you are offered two insurance plans.

    The first plan has a monthly premium of $200 with an annual deductible of $5,000.

    Your yearly cost would be $7,400 ($2,400 for premiums + $5,000 for the deductible).

    The second plan has a monthly premium of $300 with an annual deductible of $2,500.

    The annual cost would be $6,100 ($3,600 premium + $2,500 deductible). You would save $1,300 over the year for the higher-premium plan.

     
    Co-insurance - The amount you pay for some covered medical services. It is based on a percentage of the cost of that service. For example, if your plan requires a 20% co-insurance for a prescription that costs $100, you will be paying $20 or 20% of the cost.

  • Co-pays - The amount you have to pay for each prescription, doctor’s visit, lab work, hospitalization, equipment, etc.

  • Deductibles -  The amount you have to pay each calendar year before your insurance covers more of your health care bills. Deductibles can range from $0 to over $10,000 a year depending on your plan. This is often called your “out-of-pocket” expense. 

Prices from insurance companies are most reasonable when you are a member of a large group, usually because you work for an employer that offers its employees insurance coverage.

Your employer generally pays a portion of your coverage, bringing the cost down for what you pay out of pocket.

Often the larger the company you work for, the more choices of health insurance you will have available to you.

When looking at your choices, just make sure that they include coverage for hospitalization, prescriptions and durable medical equipment. After that, the rest is up to you.

Preferred Drug List and Preauthorization 

Regardless of what kind of policy you have (private or public), there may be a preferred drug list as part of your prescription coverage.

This means that there is a list of medications the insurer wants you to use before using a different medicine. If you use a drug on this list and it doesn't work for you, your CF treatment team can make a case for you to use another medication that may not be on the list but is one that they want you to have, and will try to get it covered.

Your insurance company may ask that you have preauthorization for some medications before the pharmacy fills the prescription. This usually means your treatment team must call or complete forms about why it is important for you to use what your doctor has prescribed.

This happens all the time; you should not feel badly about requesting assistance to get your medicines. It often happens with very expensive medications, or medications that are used less often for a particular infection. 

You may discover that you need a preauthorization when you arrive at the pharmacy, and the pharmacist may say that your insurance doesn't cover the medication you need. Don’t panic! This may not be a true statement. Just call your CF center and ask for help.

Most of all, it’s important to know your insurance coverage and what it covers.

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Updated 1/4/13