Understanding Health Insurance
Inflammatory bowel diseases (IBD) are chronic illnesses that require frequent monitoring, testing, and treatments. Obtaining health insurance to cover healthcare costs can be challenging for those who need it most. There are various public and private health insurance options to help individuals and families obtain affordable healthcare.
Use our IBD Insurance Checklist as a guide to evaluate and compare insurance plans.
Read below to learn more about private and publich health insurance options.
Group insurance is health insurance that you get from an employer, a union, or through a spouse’s employer or union. The employer researches available plans, selects the insurance company, and picks plan options for employees. Coverage is dependent on an individual's (or family member's) employment.
These plans are purchased by an individual to cover themselves and/or their family. As an individual, you can select insurance from individual insurance companies or from the Health Insurance Marketplace. Individual insurance plans have a variety of options, but costs and offerings may vary from state to state.
Health Insurance Marketplace
The Health Insurance Marketplace (also known as the Health Insurance Exchange) provides information on health insurance options, compares insurance plans and allows you to apply for coverage. This is helpful if you do not have coverage or would like to explore more cost-effective options. All plans on the Marketplace are considered Qualified Health Plans meaning that they must cover Essential Health Benefits (EHBs), including but not limited to ambulatory patient services; emergency services; hospital coverage; behavioral health; prescription drugs; lab services; and chronic disease management. These plans may be subsidized by the government based on your income. The Marketplace provides affordable options, but can be limited in what they cover. Click here for more information.
Association Health Plans (AHPs)
Association Health Plans (AHPs) are health insurance plans run by small employers that band together as an association. A 2018 regulation by the Trump Administration broadened the scope of small employers and self-employed individuals that are allowed to participate in AHPs. AHPs are not subject to the same regulations and patient protections as plans on the Health Insurance Exchanges. AHPs are required to provide preventive care and allow children under 26 to stay on their parent’s insurance. They are not allowed to charge persons with pre-existing conditions more, but they can base premiums on gender, age, location, and occupation. AHPs are not required to cover Essential Health Benefits such as prescription drugs. Click here for more information.
Short Term Limited Duration Health Plans (STLDHPs)
Short Term Limited Duration Health Plans (STLDHPs) are health insurance plans that are meant to cover a short gap in insurance coverage. STLDHPs are not subject to upholding patient protections like the plans on the Exchanges. STLDPs can deny coverage and charge more based on health status, impose annual and lifetime limits, and choose not to cover the Essential Health Benefits. Earlier this year, the Trump Administration extended STLDHPs from less than three months to 364 days, with the option for consumers to renew plans for up to three years. Click here for more information.
Public Health Insurance:
These health insurance plans are administered by the government. Public health insurance plans include:
Medicaid is a state-administered health insurance program for low-income families and children, pregnant women, the elderly, people with disabilities, and in some states, other adults. The federal government provides a portion of the funding and sets guidelines for Medicaid. States also have choices in how they design their program, so Medicaid programs and eligibility vary from state-to-state, and may have a different name in your state. You qualify for Medicaid based on family size and income and can apply at any time throughout the year. Visit www.medicaid.gov for more information.
Medicare is a federal government-administered health insurance program available for people age 65 or older, younger people with disabilities and people with end-stage-renal d. Visit www.medicare.gov or call 1-800-MEDICARE (1-800-633-4227) for more information.
- Medicare Part A is hospital insurance that helps cover inpatient care in hospitals, skilled nursing facilities, hospice, and home care.
- Medicare Part B helps to cover medically necessary services like doctors’ services, outpatient care, home health services and other medical services, as well as some preventive services. Most Medicare beneficiaries are enrolled in Part B automatically. This part of Medicare typically covers infusion biologic costs but frequently has a coinsurance that the patient is responsible for paying.
- Medicare Part C, also known as Medicare Advantage Plan (MAP) is a type of health plan offered by a private insurance company and is approved by Medicare to provide you with all your Medicare Part A and Part B benefits. There are many MAP types including Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPO), Private Fee-for-Service plans, Special Needs plans, and Medicare Medical Savings Account plans. Medicare services are integrated with the health plan so that the health plan benefits are coordinated with Medicare Parts A and B. Most Medicare Advantage Plans offer prescription drug coverage.
- Medicare Part D is an optional program that provides prescription drug coverage. There are two ways to get Medicare prescription drug coverage — through a Medicare Prescription Drug Plan (Part D) or a Medicare Advantage Plan that includes drug coverage. These plans are offered by insurance companies and other private companies as approved by Medicare. Part D typically covers injection biologic costs but are subject to the donut hole (below), which may result in high out-of-pocket costs.
- Medicare Part D Donut Hole/Coverage Gap is a period of time where there is a coverage gap in your Medicare D plan. Medicare Part D consists of four stages of coverage:
- Deductible: If your plan has a deductible, you usually pay the full cost of your drugs up to the deductible amount.
- Initial Coverage: During this stage, the plan pays its share of the cost and you pay a copayment or coinsurance (your share of the cost) for each prescription you fill until your total drug costs reaches $3,750 (changes year-to-year).
- Coverage Gap/Donut Hole: During this stage, you’ve exceeded the initial coverage limit of your plan so the amount you pay for prescription drugs increases. If you have noticed that you are suddenly paying more for prescription drugs, you may be in the donut hole. This stage continues until your yearly out of pocket drug costs reach $5000 (changes year-to- year).
- Catastrophic Coverage: In this stage, you have left the donut hole and you pay a 5% coinsurance amount for each prescription you fill.
Every January 1, your coverage resets back to the Deductible stage (if plan has deductible) or the Initial Coverage stage (if your plan does NOT have a deductible).
Low-Income Subsidy (LIS) or “Medicare Extra Help Program"
The LIS is for Medicare Part D recipients and Medicare/Medicaid dual eligible recipients who have limited income and resources to help pay for prescription drugs. LIS provides financial assistance to patients who may otherwise be unable to afford the costs associated with their Medicare Part D plan. Those who are eligible for LIS may:
- Receive assistance paying their monthly premium
- Have reduced or no deductible
- Have reduced or no prescription coinsurance and copayments
- Have no cap in coverage or donut hole
Most states have counseling programs that can provide free information and assistance on Medicaid/Medicare, commercial insurance, and other health care financing. The Families USA website is a helpful site to look up your state’s health care resources.
For additional assistance on selecting insurance, visit Global Healthy Living’s, “A Patient’s Guide to Insurance Enrollment”