There are several key things to look for in all available plans that can help you better compare and select your coverage.
Understanding Benefit Options
Each plan's Summary of Benefits and Coverage (SBC) will help you better understand what the plan covers. You will need to find out whether your providers are in-network, including but not limited to your cystic fibrosis care team, primary care provider, hospitals, and pharmacies. Having a full list of your medications available will also help you check the plan's formulary, a list of medications covered by the plan.
When you are selecting a health plan, it is important to note that a lower premium often means higher out-of-pocket cost for treatments and prescriptions. Similarly, a higher premium often means lower out-of-pocket cost for treatments and prescriptions. To get a sense of the overall costs of a plan, you can multiply the monthly premium by 12 and add that to the out-of-pocket maximum. There may be other costs that are not covered at all by insurance that you should keep in mind. Reviewing the plan's SBC will help provide additional information about added costs.
Key Questions and Considerations
Once you have the plan summary, a website link, or a PDF document for the provider network and plan's formulary, you can compare each plan's coverage. Key questions for a person with cystic fibrosis or their family members to ask when considering a plan include:
Cost-Related Questions
- How much do I want to pay for health insurance each month?
- What is my monthly premium and annual deductible? When do I expect to reach my deductible?
- How often am I / my loved one hospitalized? Is it important to have a plan that offers low hospitalization costs?
- How much will my preventive care cost?
- What is the plan's out-of-pocket maximum? Are all services included in the out-of-pocket maximum? (For example, some plans may not include the deductible or prescription medication costs in their out-of-pocket maximum calculations.)
- How are payments and reimbursements handled?
- Will my family also be covered under this insurance plan? If so, how will that change the coverage pricing?
- How much will I pay for out-of-network doctors, hospitals, and pharmacies?
- What are the out-of-pocket expenses for each benefit (including, but not limited to, pharmacy benefits, inpatient and outpatient care, lab tests, and visits to your care center)?
Benefit-Related Questions
- Is my CF care team in the provider network?
- Are care center visits covered? Is there a limit to how many visits are covered?
- Is durable medical equipment (such as nebulizers and airway clearance devices) covered?
- Does the plan cover inpatient hospitalization and outpatient procedures? Are there any restrictions?
- Does the plan cover in-home care? (This may be important if you use in-home IVs.)
- What is included in my plan's pharmacy benefits?
- Which medications are on the plan's preferred drug list or formulary? Which medications are not?
- Does the plan cover vitamins and nutritional supplements?
- Does the plan require coinsurance for any services or treatments?
- Are there benefits to using a mail-order or specialty pharmacy?
- Are specialty medications covered?
- Does the plan cover diabetic supplies?
- Are mental health care and substance misuse services covered?
- Does the plan cover physical and respiratory therapy?
- Are transplant services and medications covered?
Access-Related Questions
- What paperwork is required to obtain medications?
- What are the prior authorization requirements?
- Do I need a referral to see a specialist? How easy is it to get referrals for specialists from my primary care physician? How long does each referral last?
- Does my doctor need to get plan approval to admit me to a hospital?
- Does the plan offer out-of-network benefits?
- What happens if my care center is not in-network? Is there a network exception?
- What happens if the pharmacy I use is not in-network?
- Is there a specific pharmacy that I must use to fill specialty medications? Can I obtain a network exception if I want to continue using my current pharmacy?
- What do I have to do in an emergency to ensure my care will be covered?
- Am I covered when I travel or go out of state?
By working through these questions with a Compass case manager, a member of your CF care team, or a representative at your insurance company, you will have the answers to the questions that can help you find the best insurance plan for you.
Tips for Communicating With Insurance Providers
Some insurance providers may not be fully aware of the realities of life with CF or of CF treatment options. Fortunately, there are some basic strategies for communicating with a provider or insurance company that can help you advocate on your own behalf:
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Reach out for help as soon as you see a coverage problem. Waiting to resolve the issue or hoping that it resolves itself will only mean more time and complications down the road.
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Get things in writing. If something is conveyed to you verbally or you are told that a certain service will be covered, it is important that you get this in writing and save it in your records.
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Get multiple sources of confirmation. Don't be afraid to call multiple people or providers to confirm any piece of information.
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Get a name. Taking down the name of the person you are speaking with can help streamline the process and create a greater sense of accountability.
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Get a second opinion. When you are gathering important information about your insurance plan and what it covers, it is always a good idea to get a second opinion.
A Compass case manager can work directly with you to help you understand your current coverage and choices that you may have, or resolve any misunderstandings, communication errors, or issues. Connect with Compass by calling 844-COMPASS (844-266-7277) Monday through Friday, 9 a.m. until 7 p.m. ET, or email compass@cff.org.