Patient Protection and Affordable Care Act
Lupus patients no longer have to worry about being turned down for health insurance coverage due to a pre-existing condition! Visit www.healthcare.gov to find the right plan for you.
Shopping for a new health care plan can be a difficult and confusing task. This form will hopefully help you navigate this challenging, but important, decision of choosing a health plan that will best suit your and your family’s needs.
The plans on the exchange are grouped into levels (named after metals: bronze, silver, gold, platinum) based on their benefit levels and overall price, but the individual plans can vary widely. It is important for you to think about several factors when purchasing a plan on the exchange to help lower your overall costs and increase your access to needed healthcare services.
For a very handy healthcare cost estimating calculator from The National Health Council, click here.
Checklist to Choose a Health Plan
We have provided this easy to fill out checklist/form (below), which identifies key questions that can help make you an informed decision when picking a plan.
Estimating your Health Needs:
□ How many times a year do you visit a doctor? Do you see a primary care doctor, specialists, or both?
□ How many times a year do you visit an urgent care center or emergency room?
□ Have you been hospitalized in the last year? How long is your typical hospital stay?
□ Do you expect to need surgery or another major procedure in the next year?
□ Do you take any prescription medications? Include medications from a pharmacy or that are administered at the doctor’s office. Be sure to think about any medications you may have been prescribed but do not currently take because you cannot afford them.
□ Do you have any chronic conditions that could put you at risk of high health costs?
□ Do you qualify for a premium subsidy? You may qualify if your annual household income is below 400% of the federal poverty line- that’s about $46,000 for an individual and $94,000 for a family of four. You can use a premium subsidy for any plan offered on the exchange.
□ Do you qualify for assistance with the share of health costs that are not covered by insurance? You may qualify if your annual household income is between 100% and 250% of the federal poverty line – that’s about $11,500 to $28,700 for an individual and $23,600 to $58,900 for a family of four. In order to receive assistance with your share of health costs, you have to enroll in a silver plan.
Determining the Right Level Plan:
□ Do you qualify for Medicaid in your state? Eligibility varies by state, and you will be notified if you qualify during the first step of applying for an exchange plan.
□ Are you in good health with low current healthcare costs? Do you have savings you could use for unanticipated health costs? If so, a bronze or silver plan may work for you.
□ Are your health care needs and costs moderate? Are you concerned about your ability to pay for unexpected medical costs out of pocket? If so, a silver or gold plan may work for you.
□ Do you have a chronic condition or significant health care costs? Are you concerned that you may not be able to pay for unexpected health costs? If so, a gold or platinum plan may work for you.
Covered Benefits and Costs:
□ Are the services you and your family need covered by the health plan? Although all plans cover certain key benefits, there will be some variation in the services covered by each exchange plan.
□ What is the plan’s deductible? The deductible is the amount you have to pay before a health plan starts to pay for your care. Are there separate deductibles for medical and prescription drug costs?
□ What are you required to pay for physician visits? Is it different for a primary care physician or specialist? What share of hospitalization would be required to pay?
□ Does the plan you are considering limit any services to a number of visits or sessions per year? This may apply to specific types of services, like chiropractic care or physical therapy.
Coverage for Prescription Medication:
□ Are the medications you take regularly covered on the plan’s formulary? A formulary is the list of medicines covered by a health plan. The exchange website will include a link to the formulary so that you can see the list of covered medications.
Formularies typically have several tiers with patients asked to pay more for medicines on higher tiers.
□ Which formulary tiers include your prescriptions?
□ What are the costs you will have to pay for each tier?
□ Will you pay a set amount (a co-pay) or a percent of the medicine’s cost (coinsurance)?
□ Are there any steps you or your doctor will need to take before your drugs will be covered? In some cases, pans only cover a medicine once a patient has gone through step therapy, which means the patient has tried other medicines before taking one the doctor originally prescribed. Insurers also sometimes require that a doctor receive permission from a plan before prescribing a drug through a process known as prior authorization.
□ Is there a separate deductible for prescription medications? If you regularly take prescription(s) but rarely use other health services, you might spend less on health costs if you choose a plan with a lower separate deductible for prescriptions instead of one higher deductible for all costs.
□ Is there a separate out-of-pocket maximum for prescription drugs? If plans tend to require you to pay for a significant percent of the cost of your medicine and you use few other health services, you may pay less overall if you chose a plan with separate out-of-pocket maximum for prescriptions.
□ What are the options if your provider prescribes a medicine that is not on the plan’s formulary?
Access to Providers:
□ Are the physician you see regularly in the plan’s network? You should check for all physicians you may see. If you see doctors not in the plan’s network, you may be charged more in out-of-pocket costs and that spending may not count toward the limit on your out-of-pocket costs.
□ Is your preferred hospital in the plan’s network?
□ Will the plan require a referral to see a specialist or get other services?
The purpose of this tool is to help clarify some of the factors you may wish to use to understand and compare the various health plans. Each person should make an independent decision about his/her choice of a plan based on individual circumstances and appropriateness of coverage in consultation with trusted advisors. Your individual state’s Exchange should have additional information available.
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The Affordable Care Act for Women
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Sources: National Health Council, womenshealth.gov
*All images unless otherwise noted are property of and were created by Molly’s Fund Fighting Lupus. To use one of these images, please contact us at [email protected] for written permission; image credit and link-back must be given to Molly’s Fund Fighting Lupus.
**All resources provided by Molly’s Fund are for informational purposes only and should be used as a guide or for supplemental information, not to replace the advice of a medical professional. The personal views do not necessarily encompass the views of the organization, but the information has been vetted as a relevant resource. We encourage you to be your strongest advocate and always contact your medical provider with any specific questions or concerns.