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.