2024 Autoimmune Community Summit Session Recap
For many of us fall is open enrollment season. Open enrollment is the period of time when health care plans accept new or re-enrollments each year. At the recent Autoimmune Community Summit, Joanna Doran, CEO at Triage Cancer breaks down the key components of health insurance and how to get the care we need.
Joanna starts off with a staggering metric: 96% of Americans do not understand health insurance. If we do not understand our health insurance, how could we possibly get the care we need. The short answer is we can’t. So let's dive into some key areas of our health insurance plans so we can choose the best plan for us this open enrollment.
Health Insurance Costs
There are many ways we pay for health insurance throughout the year: premiums, deductibles, copays, coinsurance, and out-of-pocket maximums.
Premiums are fixed amounts that you pay each month just to have a health care plan even if you do not need care.
Deductibles are the annual amount of money you have to pay each year for your health care before the insurance company starts paying.
Copays are the amount of money you are required to pay each time you receive a healthcare service like visiting your primary care physician or going to the emergency room. Each service might have a different copay amount.
Co-insurance or Cost Shares are the difference between what you pay and your insurance company pays for a health care service. For example, your plan might say that the insurance company will pay 80% and you pay 20%.
Out-of-Pocket Maximums are the most you will pay in a year for your health care. After you hit this amount, your insurance company will pay 100% of the cost.
Understand How Your Plan and Prescription Formulary Work
Not all healthcare plans are created equal. Marketplace plans include your prescription costs, your deductible and your copays in your out-of-pocket costs for the year. Whereas employer plans can separate those costs out so only some of those costs hit your out-of-pocket maximum.
Something else to take into consideration is that family plans have individual out-of-pocket maximums and family out-of-pocket maximums.
How to Choose a Health Care Plan
Now that you know all the ways that you pay for your health care, how do you know which plan is the cheapest? When you look at the health care plans offered to you, you will probably see that each plan has a different deductible, different copays and different coinsurance. You have to compare the plans and all the costs and do the math.
To calculate the total cost of a plan, multiply the monthly premium by 12 then add the out-of-pocket maximum to it and that is your total cost for the year.
(Monthly Premium *12) + Out-of-Pocket Maximum = Total Cost for the Year
While cost is important, you also need to make sure that the plan that you choose covers the providers you want to see and the prescription drugs that you need. You might find that the cheapest plan does not cover your doctor or your medications and then you end up paying out of network costs or paying out-of-pocket because your insurance won’t cover it.
Enrollment Timelines
Different types of plans have different time periods where you can enroll in their plans, but most are in the fall or winter. If you have a major life event like switching jobs or getting married, there are exceptions to allow you to enroll at that time.
Employer Plans: Enrollment periods vary, but are usually in the fall.
Medicaid: Allows enrollment at any time during the year
Medicare: October 15th to December 7th
Marketplace Plans: November 1st to January 15th
Denial of Coverage Appeals
So you select a health care plan and three months in you go to your doctor and get prescribed a new treatment that you need. You get all excited and then your health insurance company denies it. Not to worry, you can appeal.
There are two types of appeals:
Internal appeals are when you go back to the insurance company and ask them to reconsider their decision.
External appeals are where an independent entity that is not part of your insurance company reviews your appeal.
50% of the time patients are successful in getting the decisions overturned during appeal.
Triage Health has a guide to help you with your next appeal.
Managing Medical Bills
Healthcare costs are already high, so let's talk about how to make sure you are only paying for what you need to.
Wait for the Explanation of Benefits (EOB) from your insurance before paying a bill to ensure that the EOB cost matches the cost on the bill. If the bill is higher that means the provider sent you the bill before it was processed by insurance.
If you cannot afford your bill, reach out to Dollar For. They can help you qualify for and obtain hospital financial assistance.
You can sometimes negotiate bills or set up payment plans with your provider, but you have to ask.
Use pharmacy discount cards like NeedyMeds and GoodRx. These discount cards are sometimes cheaper than your insurance and all you have to do is give the card to the pharmacist.
For more tips or information on these resources check out Triage Health's resource guide.
Knowing Your Rights at Work
If you have an autoimmune disease, chances are you will have to take time off due to your disease. Whether it is for a treatment or a flare, there are laws and employee benefits to help you.
There are two types of laws that can help you, fair employment laws and leave laws. Fair employment laws include things like the Americans with Disabilities Act which prevents discrimination for patients and caregivers and also requires accommodations for those with disabilities. This for example can help you get an ergonomic desk setup or protect you from discrimination during hiring. Another important set of laws are leave laws. FMLA, the Family Medical Leave Act, is the most commonly known, but there are also similar laws at the state, county and city levels. These laws allow you to take up to 12 weeks of unpaid leave for health reasons.
In addition, many employers offer other leave benefits, such as a short-term and long-term disability. These benefits allow you to take time off when you are disabled either temporarily or permanently.
To learn more, visit https://www.triagehealth.org/.
Recordings from the 2024 Autoimmune Community Summit are available on YouTube.
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