NAVIGATING HEALTHCARE

Health Insurance 101: Navigating Coverage With CIDP

With so much to learn about CIDP (chronic inflammatory demyelinating polyneuropathy), understanding the details of health insurance can feel overwhelming. Knowing the basics may help you move forward a little more confidently.

Whether you’re newly diagnosed with CIDP or you’ve been living with it for some time, you may be unfamiliar with some of the language or specifics of health insurance coverage.

Maybe you’ve found yourself in a new situation that brings a change in coverage. “Often, just when you start to figure out how your coverage works, your life changes,” said Clara, a healthcare financial navigator who helps people understand their coverage and affordability options. “You change jobs and have a lot of new plans to choose from or you need to switch from Medicaid to an employer-sponsored plan.”

Another situation some people with CIDP may go through is being prescribed a treatment that requires them to understand their coverage for prescriptions or in-home care. No matter where you are in your CIDP journey, having a basic understanding of your health insurance coverage can be helpful. You never know when you might need it!

This article is only intended to serve as a general overview and is not meant to provide advice on which insurance plan you should select. Only a health insurance professional who understands your unique circumstances will be able to make specific recommendations.

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Do you have questions about health insurance coverage? This guide may help you understand how coverage works for CIDP treatments.

How health insurance works

Health insurance helps pay for part of your medical care. That can include doctor’s visits, procedures, prescriptions, and more. Generally, plans fall into 2 categories.

Private insurance

Also called commercial insurance, these plans are administered by a private insurance company, rather than the government. Some people have private insurance through an employer or through a plan they’ve enrolled in via the Health Insurance Marketplace.

Public insurance

This is insurance that’s provided by the government, usually to a specific group of eligible people. A few examples of public insurance are Medicare, Medicaid, and Veterans Affairs coverage.

Private insurance: choosing a plan

If you’re choosing a commercial plan, there are a few things to keep in mind as you figure out what plan is right for you. But first, here are a few important terms to understand:

  • Premium: the amount you pay for health insurance every month
  • Deductible: the amount you pay for covered healthcare services before your insurance plan starts to pay. With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself
  • Co-pay (co-payment): a fixed amount ($20, for example) you pay for a covered healthcare service after you’ve paid your deductible
  • Co-insurance: the percentage of costs of a covered healthcare service you pay (20%, for example) after you’ve paid your deductible
  • Network: the doctors, facilities, providers, and suppliers your health insurer or plan has contracted with to provide healthcare services—these are known as in-network providers. In contrast, out-of-network providers are those doctors, facilities, providers, and suppliers who do not have a contract with your health insurer. Out-of-network providers will typically charge a higher rate and may cost you more money
  • Out-of-pocket maximum: the most you have to pay for healthcare services in a plan year. After you spend this amount on deductibles, co-payments, and co-insurance for in-network care and services, your health plan pays 100% of the costs of covered benefits

Questions to consider

What type of plan is it? The type of plan you have can affect how much you pay for care and what doctors your plan will cover. There are several types of plans out there. The following are some of the most common:

  • HMO (health maintenance organization): a type of health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO. It generally will not cover out-of-network care, except in an emergency
  • PPO (preferred provider organization): a type of health plan that contracts with medical providers, such as hospitals and doctors, to create a network of participating providers. You generally pay less if you use providers that belong to the plan’s network
  • HDHP (high deductible health plan): a plan with a higher deductible than a traditional insurance plan. The monthly premium for this type of plan is usually lower, but you pay more healthcare costs yourself (your deductible) before the insurance company starts to pay its share

If you’re living with CIDP, it may be a good idea to determine whether your current healthcare team, including any specialists such as your neurologist, are covered under the plan you’re considering. If you are facing a network change within your current plan, be sure to check if the members of your healthcare team are still in network. 

What’s the real cost of this plan? Lower monthly premiums don’t always mean lower cost overall. One way to get a rough estimate of your overall cost is to total up the annual premiums for each of your plan options, and then add that number to the plan’s deductible. This will give you an idea of what you might actually spend over the course of the year.

What is the coverage for prescriptions with this plan? Some plans may cover prescriptions under medical benefits, and some may cover them under a separate prescription benefit. Checking this detail for each of your plan options can help you determine how much you’ll pay for any medications you take to help manage CIDP.

Public insurance: a few quick facts

Medicaid

Medicaid is available only to certain low-income individuals and families who fit into an eligibility group that is recognized by federal and state law, like those living with disabilities.

Each state runs its own Medicaid program that follows federal guidelines. These guidelines are broad, so Medicaid eligibility and coverage can vary from state to state. Learn more about Medicaid eligibility.

Medicare

Medicare is run by the federal government, rather than each state. It’s a public health insurance program for people who are 65 and older, as well as eligible younger people with certain disabilities.

Medicare has 4 “parts” that cover different aspects of healthcare:

Part A—hospital insurance: helps pay for inpatient care in hospitals and other facilities, like hospice or skilled nursing facilities. It may also cover some types of home healthcare.

Part B—medical insurance: Helps pay for services from healthcare providers, including doctor’s office visits, outpatient care at a hospital, and certain types of preventive services. It may also cover home healthcare or medical equipment. It does not include prescription drug coverage.

Part C—also called Medicare Advantage: A type of Medicare health plan in which all your Part A and Part B benefits are offered by a private company that contracts with Medicare. These plans may also offer prescription drug coverage.

Part D—prescription drug coverage for people with Medicare plans: Optional coverage to help pay for prescription drugs. It is important to understand that, although Part D is optional, people with Medicare plans must enroll in Part D to receive any coverage for their prescribed medications.

When to enroll in a plan

Open enrollment is the yearly period when people can enroll in a health insurance plan or change plans. This often happens in the fall, but that can vary from plan to plan, so be sure to check with your employer or insurance provider to get your open enrollment dates.

Even if you already have coverage, Clara recommends reevaluating your options when open enrollment rolls around—especially if you’re looking to lower costs. She advises, “If you’re wishing you’d picked a different plan last year, open enrollment is your chance to see if there’s a choice that may be better for you in the coming year.” 

There are specific events that allow you to change plans outside of open enrollment, like getting married, having a baby, or changing jobs. And some public plans, like Medicaid, allow you to enroll any time of year.

Navigating costs and coverage

Choosing a plan is one thing; navigating coverage for CIDP treatment is another.

You may want to start by asking your doctor if you are eligible for any dedicated patient support programs, though some of these programs are not available to everyone.

There are also programs that can help your doctor with navigating your coverage, providing prior authorization requirements, and finding options for cost savings and assistance. These types of programs can be a great help to both you and your provider.

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Do you have questions about health insurance coverage? This guide may help you understand how coverage works for CIDP treatments.

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