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Health Insurance

Unless you win the lottery and have an unlimited amount of money to spend on your health care, having health insurance to cover your treatment expenses will most likely be very important throughout your adult life.

When Should You Start Thinking About Getting Health Insurance?

If you are 18 years of age or younger and receiving Medicaid and CHIP (Children’s Health Insurance Program), know that coverage under these public insurance programs will likely end when you turn 19. However, if you have children or you are deemed disabled, you could continue receiving benefits under Medicaid. Also, additional changes are coming as a result of the Affordable Care Act (ACA), the federal health care reform legislation signed into law in March 2010. Starting on January 1, 2014, Medicaid coverage will be expanded to cover most people under age 65 with an annual income of approximately $15,000 for a single individual; incomes for families will be higher.

Previously, if you were covered under a parent’s private insurance policy, your coverage would end when you turn 19, unless you were going to school full time or lived in a state that had a higher age limit. Not anymore! The ACA helps young adults by allowing them to remain on a parent’s plan as dependents until they are 26.

So, if you leave school before you’re 26, can you continue to be covered under your parent’s insurance policy? Thanks to the ACA, you can. But there is a situation in which this doesn’t apply. If you become eligible to purchase employer-sponsored health coverage before you are 26, the law does not require your parent’s plan to enroll you if the plan has been around on or before March 23, 2010. In 2014, this exception will no longer apply.

What if you’re married? It doesn’t matter. Regardless of financial dependency, marital status, or school enrollment, you are guaranteed the option to be covered under your parent’s plan up to age 26. Keep in mind that this is only the case if your parent’s health plan offers dependent coverage, and while you can continue to be covered, your spouse cannot.

What if you or your partner gets pregnant? If you are 26 or older, you will need your own insurance coverage whether or not you are pregnant. If you are 25 or younger and still covered by a parent, you can continue to be covered, but be aware that your spouse or child will not be able to join your parent’s plan as dependents.

So, if you’re not covered under your parent’s insurance plan or if your 26th birthday is fast approaching, it’s time to start thinking about getting your own insurance coverage.

For more information, go to Affordable Care Act.

Getting Insurance If You’re Unemployed or Your Employer Doesn’t Provide Insurance

The health insurance market in the United States has two main components: group and individual.

  • Group Market. Provides health insurance plans to employers. Employers then make plans available to their employees. Employers usually cover a large amount of the cost, making plans affordable for people who work for them. Employers can limit employee participation in group insurance based on certain situations, such as hours worked, but they CANNOT deny a worker insurance based on health status.
  • Individual Market. People buy insurance policies directly from insurance companies. People may purchase insurance through the individual market for a variety of reasons. For example, some employers do not provide insurance plans. In other cases, a worker may not meet an employer’s eligibility requirements, may not feel that the employer’s plan is right for his or her health needs, or may be self-employed or unemployed. In the individual market, insurance companies CAN deny insurance coverage or increase charges because of pre-existing medical conditions. Although this is no longer allowed due to the passage of the Affordable Care Act, the law won’t take effect for adults until 2014. However, since September 23, 2010, children under age 19 cannot be denied coverage.

If you’re not eligible for group insurance and cannot obtain or afford individual insurance, you may want to find out if you live in a state that has a high-risk pool or if you qualify for the federal high-risk pool (ie, the Pre-Existing Condition Insurance Plan [PCIP]).

For more information on the PCIP, click here.

Health Insurance as a Foreign Language

EOBs. Copays. HMOs. PPOs. Coinsurance.

If you’ve ever dealt with health insurance, you know that just learning the lingo can be a challenge.

So before you become befuddled, baffled, and bewildered, go to Insurance Basics.

Many states have implemented high-risk pools, which are organizations that offer health insurance to people who cannot obtain insurance because of their health status. A high-risk pool is a comprehensive health insurance program. Although there are some affordable high-risk pools, premiums in many pools can be expensive. Some states have discount programs.

Where to Learn About Insurance Options

Insurance is complicated. All plans are different, both in eligibility requirements and the coverage they offer. While the Internet is full of information, you may want to talk to people who can help you figure out what type of plan is best for your health care needs.

Here are some places to go for help:

  • Your Hemophilia Treatment Center (HTC).
  • A local bleeding disorder organization.
  • State insurance departments.
  • School (such as university or college).

What to Look for in a Health Insurance Policy

The numerous financial factors and policy differences among health insurance providers for people with bleeding disorders often makes choosing a health insurance policy a challenge.

Click on the links below for tips on how to navigate your insurance options.

How Much Prescription Coverage Is There?

Some plans limit the yearly amount of money that they pay for prescriptions. Figure out your annual medication costs and compare these numbers.

What About Pre-Existing Conditions?

Check the plan for any clauses about pre-existing conditions. Effective September 23, 2010, you cannot be denied insurance coverage based on a pre-existing condition if you are under age 19. (Note: this does not apply to grandfathered individual health insurance policies, which are policies that you bought on or before March 23, 2010.) Effective January 1, 2014, insurance companies will no longer be allowed to refuse anyone coverage based on pre-existing conditions. The law also prohibits insurance companies from charging higher rates based on health status.

If you have a pre-existing condition you may want to look into a pre-existing condition insurance plan (PCIP), also known as a high-risk pool. A PCIP makes health coverage available to you if all of the following are true:

  • You are a United States citizen or reside in the United States legally.
  • You have been denied health insurance because of a pre-existing condition.
  • You have been uninsured for at least six months.

Are There Annual Limits?

This is the maximum amount of money that an insurance company will pay for your care each year.

On January 1, 2014, insurance companies will no longer be able to have annual limits. Until then, the law sets a minimum annual limit that insurance companies can impose. This applies to all group policies and to new individual policies. For a plan or policy year beginning on or after September 23, 2011, but before September 23, 2012, the minimum annual limit cannot be under $1.25 million. For plan or policy years starting on or after September 23, 2012, but before January 1, 2014, the annual limit cannot be under $2 million.

Is There a Lifetime Limit?

This is the maximum amount of money that an insurance company will pay for your medical care over the lifetime of your policy.

In the past, it was possible to reach your lifetime coverage maximum in just a few years if you had very high medical costs. Fortunately, after September 23, 2010, no group or individual health plan can have a lifetime limit. (Note: This change does not apply to grandfathered plans, which are plans that were in place by March, 23, 2010.)

Does the Policy Have an Out-of-Pocket Maximum?

An annual out-of-pocket maximum places a limit on how much you will spend each year for deductibles, copayments, and other cost sharing.

It’s important for you to know your out-of pocket maximums, so you will not be surprised by having to pay sky-high amounts during a year that you receive a lot of expensive medical care. Be aware, however, that not all the money you spend on health care applies to the out-of-pocket maximum. Copayments on prescriptions, for example, can sometimes be excluded. Check your policy carefully!

What’s the Premium?

The premium is the amount you pay each month for the insurance plan. You pay the premium even when you don’t use any health services under the plan.

What’s the Deductible?

The deductible is the amount you must pay out of your own pocket before the insurance plan will pay for any medical services that you receive. The deductible may not apply to all medical services (for example, preventive care).

What's the Copay?

A copayment is a fixed fee that insurance companies require you to pay for some services that they cover.

For example, every time you visit a doctor for a covered service, you may have to pay $20. There are often copays on prescriptions. In general, copays for generic drugs are less than copays for brand-name drugs. Some very expensive drugs have copays as high as 50% of the list price, or they may not be covered at all. Check to see which services have copays and how much they are.

How Is Factor Billed?

Some insurance plans cover factor as a prescription; some cover it as a medical item. Know what your factor will cost you. If it is under medical, you may reach the annual maximum faster.

What Are the Copays for Emergency Room Visits?

How much will you have to pay each time you go to the emergency room?

You should be able to go to the emergency room when necessary instead of staying at home with a severe bleed because you fear the medical costs.

Is Your Doctor in the Plan's Network?

Private health insurance plans (group and individual) typically have networks of hospitals, health care facilities, doctors, and pharmacies that they have contracted to care for plan members.

If you visit a facility or use a doctor or pharmacy that is out of the network, you may have to pay more. You may want to make sure that your Hemophilia Treatment Center (HTC) is in network.

Is Routine Care Free?

Know what your insurance plan considers routine care.

Be sure that you are aware of any costs associated with your care, such as maintenance office visits, blood draws, and visits with a nurse or nurse practitioner.

What About Mental Health Visits, Long-Term Care Options, and Disability Care and Insurance?

Not all medical costs are covered by insurance.

If you visit a mental health professional or think you might like to in the future, check with your plan to see if it is covered.

Here are helpful worksheets and guides: