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Insurance Basics

People with bleeding disorders, including hemophilia, may find coverage for their health care and medications through the following types of insurance:

  • Private insurance: this type of coverage is owned by the individual. The 2 main types of private plans in the United States are indemnity health care (called fee-for-service) and managed health care
  • Government programs: people with hemophilia may rely on government programs, such as a federal or state high-risk insurance pools, Medicaid, or Medicare to help cover their health care needs to varying degrees
  • Financial aid: some nonprofit organizations and chapters provide short-term help to people with bleeding disorders in paying their insurance premiums. These are not long-term solutions, but can help in certain situations

Parents/patients get so many items related to their bleeding disorder in the mail every day, it's very easy to ignore them. With so many changes going on, now more than ever it's critical to open and read every piece of mail from your insurance company.

Insurance Definitions

Here are definitions of some of the commonly used health care insurance terms to describe out-of-pocket expenses. These are the amounts (either in dollars or percentage of the cost) that are not covered by insurance that the enrollee in an insurance plan must pay.

Common Insurance Definitions
Deductible The out-of-pocket dollar amount that you are responsible for paying (usually yearly) before insurance benefits begin
Co-payment (called co-pay) The established out-of-pocket dollar amount that you must pay for a specific service (for example, a doctor office visit, physical therapy, a prescription). This is often a set dollar amount
Coinsurance The percentage of the cost that you must pay (in addition to the deductible) after the insurance company pays. The amount is usually expressed as a ratio (sometimes called 80:20). In this example, the insurance company pays 80% and you pay 20% of the remaining bill
Out-of-pocket limit The maximum out-of-pocket dollar amount that you must pay (usually yearly) for the deductible and coinsurance limit
Coinsurance limit The maximum annual out-of-pocket dollar amount that you must pay for coinsurance costs (for example, 20% or up to $2000)

Types of Insurance Options

What are your options?
  • Enrollee must choose a physician as a PCP
  • Based on the premise that covering preventive care while controlling costs will result in better health care and lower rates of health care inflation
  • PCP is the "gatekeeper" for all medical services
  • Only the PCP can authorize referrals to other providers for specialized care or tests
  • No benefit coverage is provided for services rendered by any nonreferred physician or facility
  • Significantly lower premiums are charged
  • Typically, the enrollee pays a co-payment—usually nominal—and there is no deductible or coinsurance
  • Payment mechanism is the same as traditional indemnity
  • Expenses are reimbursed after coinsurance and deductible amounts are met
  • Coinsurance is higher when out-of-network
  • No referral process is required
  • Enrollees may see any physician desired
  • Coinsurance percentage is lower if enrollees utilize physicians and facilities that are contracted with the plan’s provider network
  • Can use non-network providers if willing to pay a higher coinsurance percentage
  • No requirement that plan enrollees choose a PCP
  • Enrollees are reimbursed for covered expenses incurred due to sickness or injury
  • Expenses are reimbursed after coinsurance and deductible are met
  • Most modern traditional plans include some elements of managed care
Point of Service
  • Combines features of HMO and PPO plans
  • Allows patient to use in-network or out-of-network providers and still receive some level of benefit
  • In-network benefits require referral from PCP for all services (for example, specialist visits), and enrollees are charged a small co-payment
  • Enrollees choosing to go out-of-network or bypass the PCP will pay higher out-of-pocket expenses

HMO = health maintenance organization; PCP = primary care provider; PPO = preferred provider organization.

What Is an EOB?

After you've visited a doctor, clinic, or hospital, an Explanation of Benefits (called EOB) from the insurance company tells you and your health care provider what portion of the charges are eligible for benefits under your insurance plan. The EOB is the result of the claims process. Remember, the EOB is not a bill.

Health Insurance Check List

Here are some questions to ask when exploring various health insurance plans:

  • What type of plan is it? Is it an HMO (health maintenance organization), a PPO (preferred provider organization), or a traditional plan?
  • Does the policy cover prescription drugs? If so, is this through a separate drug provider?
  • How does the policy cover blood products/clotting factors?
  • Does the policy cover home care services?
  • Is clotting factor covered on the prescription coverage or under another category such as Major Medical?
  • Is separate coverage available for drugs under a drug plan?
  • Does the policy provide coverage in the event of catastrophic illness?
    • If so, is it adequate?
  • Would you have to see only those physicians in the plan's network?
    • If not, what is involved in going out-of-network? Is there the possibility of negotiating with the insurer to cover an annual Hemophilia Treatment Center (HTC) visit under an in-network cost (even if the facility is out-of-network) based on the statistics of how much better patients do when seen by an HTC?
  • What deductibles would you have to pay annually?
  • What would your co-pay be for?
    • Office visits
    • Prescriptions
    • Emergency room visits
    • Hospital care
    • Laboratory services
    • Physical therapy
    • Supplies (called durable goods)
  • Does the plan's policy have a preexisting conditions clause? (As of Jan 1, 2014, all these restrictions on preexisting conditions will be removed under health care reform)
    • If so, how long is the waiting period?
    • Can the waiting period be waived?
  • If my employer changes insurance carriers, will my benefits change?
    • If so, will anything be different under the new coverage? How?
  • Will the policy cover medical services provided in other states?
  • Does the policy restrict the delivery of medical services to specific types of health care facility providers (that is, in-network vs out-of-network)?
  • Does the policy require prior authorization for coverage of medical services or procedures? Is it required for services by in-network providers or out-of-network providers?