REVIEW YOUR HEALTH COVERAGE: Recent Federal Law Lowers Costs, Opens Up New Options

When reviewing potential health plans (and when considering whether to renew your existing plan), please review all plan provisions carefully. You will want to closely read the “general provisions” (length of policy, types of providers you can see, term definitions), the “drug provision” (are your bleeding disorders products, and any other drugs you need, covered by the plan), and the provisions that describe claims and the payment of claims. The ACA requires that plans spell out insurance terms in easily understood language.

After reviewing any potential plan, you should be able to answer the following questions:

  • What is the overall annual deductible?
  • Are there separate deductibles for specific services?
  • What is the annual out-of-pocket limit on my expenses?
  • What is not included in the out-of-pocket limit?
  • Is there an overall annual limit on what the plan pays?
  • Does the plan use a network of providers? Are my key providers (hematologist, specialty pharmacy, etc.) in-network?
  • What do I pay for out-of-network care?
  • Do I need a referral to see a specialist?
  • Are there any services the plan doesn’t cover?
  • Does the plan use a preferred drug list and, if so, will my product of choice be covered?
  • Is my product covered under the pharmacy benefit or under the medical benefit?

If you cannot answer these questions, seek help and clarification from your company’s human resources department (for an employer-sponsored health plan), your HTC social worker or an ACA Marketplace assister (if you are selecting a plan via the Marketplace.)

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