Understanding available insurance op ons and what choosing the

Understanding available insurance op3ons and what choosing the right insurance can mean for your health and your finances. What Services are available? CVC offers both financial and non-­‐financial services to our pa3ents to help address many aspects of living with a chronic illness CVC is a diagnosis specific organiza9on which supports: •  Narcolepsy •  Excessive Day1me Sleepiness (EDS) •  14 other Diagnoses Copayment assistance is available only for prescrip9on medica9ons FDA-­‐approved to treat a CVC-­‐supported Diagnosis •  Assistance from the ini1al applica1on through the Administra1ve Law Judge level •  Support and recommenda1ons to help answer “Should you apply for SSDI?” • 
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Explain current benefits Facilitate applica1on process through Medicaid Ensure 1mely elec1on of COBRA benefits Provide Medicare program educa1on and enrollment assistance –  Medicare Supplemental Policies (Medigap) –  Medicare Advantage –  Medicare Prescrip1on Drug Plans (Part D) •  Assistance applying for state and federal programs to reduce prescrip1on costs –  Extra Help Program (LIS) –  State Pharmaceu1cal Assistance Programs (SPAP) •  Facilitate research of and enrollment in individual insurance coverage CVC is a Cer9fied Applica9on Counselor Designated Organiza9on (CDO) and has several staff members trained to assist individuals through the Marketplace •  Create an account •  Complete an Applica1on •  Review eligibility determina1on as assessed by the Marketplace •  Compare plan op1ons available in your area •  Enroll in coverage •  Refer to appropriate CVC department if financial assistance is needed What does it take to obtain insurance or change your current insurance? What does having insurance mean for your health and benefit op9ons? How will elec9ng insurance affect your finances? •  Medicare Part A and/or Part B –  January 1 – March 31 each year •  Medicare Advantage or Medicare Prescrip1on Drug Plans –  October 15 – December 7 each year •  Health Insurance Marketplace or Individual Coverage –  November 15 – February 15 each year Limited plans available outside OEP – research op9ons at hXps://finder.healthcare.gov Most common qualifying events: •  Loss of insurance –  Insurance must be considered minimum essen1al coverage –  Loss cannot be due to fault of member such as non-­‐payment •  Moving to a new insurance coverage area •  Change in immigra1on or ci1zenship status •  Marriage or divorce For a full list of SEP Qualifying Events, visit: • 
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www.healthcare.gov www.medicare.gov Make the process easy by: •  Keeping documents from prior insurance coverage –  Explana1on of benefits documents –  Invoices from medica1on purchases –  No1fica1on of creditable coverage –  Proof of termina1on date of last insurance policy •  Knowing demographic and health informa1on for yourself and any dependents –  SSN –  DOB –  Address –  Is group coverage available for anyone? Make the process easy by: •  Having knowledge of insurance terms –  Decipher jargon by using helpful insurance glossaries »  Deduc1ble, out-­‐of-­‐network, donut hole »  www.healthcare.gov/glossary –  Ask someone familiar with insurance to explain key terms •  Knowing deadlines –  When can you sign up? »  Be proac1ve when you enroll; don’t wait un1l the last minute! –  When will new coverage start? –  When is your first premium payment due? Make the process easy by: •  Researching all coverage op1ons you are eligible for in your area beforehand •  Medicare op1ons: –  Original Medicare (Part A and/or Part B) –  Medicare Supplemental Insurance (Medigap) –  Medicare Prescrip1on Drug Coverage (Part D) –  Medicare Advantage (Part C) What type of plan is best for your needs? •  Health Maintenance Organiza1on (HMO) –  Strict network of doctors and facili1es –  Referrals required to visit specialist –  Oeen have lower premiums •  Preferred Provider Organiza1on (PPO) –  Open network of doctors and facili1es –  No referrals required –  Oeen have higher premiums •  Point of Service (POS) –  Strict network of doctors and facili1es (with excep1ons) –  Flat fees charged for each type of service received What is a Drug Formulary? •  Indicates which “1er” drugs are classified under –  Check prices for each 1er •  Check the formulary by accessing plan informa1on –  www.healthcare.gov –  www.medicare.gov –  Insurance plan’s website •  Call the plan and speak to a representa1ve What does it mean if your drug has a restric9on? •  Prior Authoriza1on (PA) –  Doctor must explain “why this drug?” before coverage is approved •  Quan1ty Limit (QL) –  How many tablets will be covered each month? •  Step Therapy (ST) –  The plan will cover this drug, but only if you try (X) or (Y) drug first Prior authoriza9ons and drugs “Not on Formulary” •  What’s the difference? •  How to get your drug covered: –  Ask doctor to file a request with insurance »  Prior authoriza1on request »  Formulary excep1on request –  Start as soon as possible –  Takes about 48-­‐72 hours aeer request is submiXed –  Insurance policy will no1fy you of decision via mail •  Lowest costs at preferred pharmacy •  Determine any excep1ons that need to be made for drugs that are only available through specific pharmacies •  Confirm that mail order prescrip1ons are covered –  If mail order prescrip1ons are not covered, does the insurance plan make an excep1on for drugs only available through mail order? Does the OOP max apply to: •  Medical benefits only? •  Prescrip1on benefits only? •  Medical and Prescrip1on benefits combined? Is it a true Out-­‐of-­‐Pocket? •  Will you s1ll be responsible for certain costs? –  Copayment to visit a primary care physician What does the benefit maximum apply to? • 
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Medical services? Prescrip1on costs? Nursing benefits or home care? Durable medical equipment? Determine any other coverage limits that may apply •  Allowing only 3 visits to a specialist per year Consider if the premium amount is affordable. If not, is there a source of assistance available? •  Caring Voice Coali1on •  Subsidies through the Health Insurance Marketplace •  Help with Medicare premiums –  Extra help program (LIS) –  State Pharmaceu1cal Assistance Programs (SPAP) –  Qualified Medicare Beneficiary (QMB) programs How to balance premium costs with costs for medical services and prescrip9ons? •  Bronze Level –  Member is responsible for 40% of medical service costs –  High deduc1bles –  Lowest premiums available •  Silver Level –  Member is responsible for 30% of medical service costs –  Deduc1bles range from $1500 -­‐ $3500 –  Average Premiums How to balance premium costs with costs for medical services and prescrip9ons? •  Gold Level –  Member is responsible for 20% of medical service costs –  Lower deduc1bles ranging upward from $500 –  Above average premiums •  Pla1num Level –  Member is responsible for 10% of medical service costs –  Low deduc1bles –  Highest premiums –  May not be available in all areas •  Deduc1ble •  Coinsurance or copayment •  Out-­‐of-­‐Pocket maximum –  Is deduc1ble included or separate? –  Is it a true Out-­‐of-­‐Pocket maximum? •  How much do prescrip1on drugs cost? –  How many medica1ons are you taking? –  How oeen do you need to fill each prescrip1on? How to lower costs: •  Consider all assistance programs you may be eligible for –  Manufacturer copay coupon cards –  Caring Voice Coali1on »  Copayment assistance »  Premium assistance –  Federal and State programs »  Extra help through Social Security »  SPAP programs Keep a list of addi9onal programs that can offer guidance and help when needed: •  Narcolepsy Network –  hXp://www.narcolepsynetwork.org •  Support groups •  Online forums •  Awake in America –  Grants to assist with cost of a sleep study for diagnosis purposes –  hXp://www.awakeinamerica.org If you have ques-ons about insurance op-ons and benefits or would like to speak to a Case Manager to see if you may qualify for assistance, contact Caring Voice Coali-on. Come visit us at our booth in the Exhibit Hall for more informa3on.