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Financial Health
Verifying New Employer Coverage for Factor Products
By David Linney
*Editor’s Note: This article does not deal with pre-existing condition
clauses, insurance-plan effective dates or the issue of employer size as they
relate to new employer insurance.
“How will my new employer’s insurance cover factor products? And how can I find
out?” These are questions that can cause a few sleepless nights for consumers
coping with high-cost bleeding disorders.
New Insurance
New health insurance options usually come with a new job. A common dilemma for
job seekers, however, is whether to take a new position without knowing the
details of insurance coverage for necessary factor products.
It is generally best to seek new employment with larger companies because
benefits are generally more stable. High-cost factor product bills are less
likely to have a significant impact on a larger employer’s premium costs. The
impact of high costs on a smaller employer, however, often is dramatic. Premium
costs can increase over time to such a point that some smaller employers could
be forced to drop insurance coverage altogether.
After making sure a prospective employer indeed offers insurance, how can you
determine if the plan provides good coverage for factor products?
The problem is that you usually cannot verify new insurance benefits until you
are an actual policyholder. By that time, though, you are already locked in with
the new job and/or a new plan and it could be too late to change jobs or switch
plans.
To verify coverage, you could go to the prospective employer. However, this can
be awkward, as a job seeker may not feel comfortable with the loss of privacy
that comes with disclosing a bleeding disorder or the bleeding disorder of a
family member in order to verify factor product coverage. While job
discrimination as a result of disclosure should not happen, it is a
possibility that should be considered by each individual.
Before considering such an option, other steps can be taken. You certainly can
check to see whether your hemophilia treatment center (HTC) or factor product
vendor has experience with the same employer group insurance plan. This
may be a long shot, but it is worth investigating, especially with the larger
employers. Make sure to check out the correct insurance plan, and not
just the insurance company because each employer decides on a particular
benefit plan to purchase from the insurer, and health and drug coverage can vary
among different employers’ plans.
Verifying Coverage
A good, simple method job
seekers can use to verify factor product coverage involves asking the following
questions and obtaining critical information. Although it is not always
foolproof, it is quite accurate.
Factor products are drugs
approved by the Federal Drug Administration (FDA) and are deemed “medically
necessary.” This means they are almost always covered by insurance. (There are
only a few cases in which an insurance plan did not provide coverage for factor
product.)
• First question: How are
factor products covered by the insurance plan?
Factor products are covered
by insurance as either a health or drug benefit. Drug benefits are commonly
provided through separate drug plans, often through a specialty pharmacy
affiliated with the drug plan. Knowing this is helpful.
• Second question: What
coverage does the insurance plan provide for factor products?
If you assume factor products
are covered as either a health or drug benefit, you can check out both the
health and drug coverage. If both are OK, then you should be confident that
there is adequate coverage for factor products.
Obtain a current copy of the
employer’s health and drug benefits booklet(s) or a detailed health and drug
benefits summary to check out the coverage of both. You can contact your
employer’s human resources department to review general questions. If you need
additional help understanding the benefits, contact
the insurance company itself, your local
HTC, or your home care company (HTC or private company), but be prepared for a
potential conflict if your current home care company is not “in-network” with
the new insurance plan. While reading your employer’s coverage information, pay
close attention to the following:
• For the health benefit—Check
out in-network providers, deductibles, co-insurance, out-of-pocket expense
limits, in-network versus out-of-network coverage and lifetime limits. Also
calculate your maximum out-of-pocket liability and determine if there is any
lifetime limit relative to your usage of factor.
• For the drug benefit—Check
out in-network pharmacies and/or specialty pharmacies, co-payments or
co-insurance, out-of-pocket limits and any annual limit on drug expenditures.
Also calculate your maximum out-of-pocket liability and determine if there is
any problem with a low annual limit.
• Third question: How good
is the coverage?
If out-of-pocket costs are
reasonable for both health and drug benefit coverage and there are no problems
with either a low annual or lifetime limit, your insurance should adequately
cover factor products.
Once your new insurance
becomes effective, work directly with your HTC to verify specific health or drug
benefit coverage for factor products and determine which home care vendor(s) you
can use. You also can contact your current home care vendor to help verify this
information, but recognize that new insurance either may not cover your current
vendor or your current vendor as an in-network provider.
Following up in a timely
manner will help ensure that there are no gaps in your ability to order new
factor supplies.
Learn More…
For more information on insurance coverage and employee health benefits, contact
the NHF Information Resource Center at (800) 42-HANDI.
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