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Health Insurance FAQ's

Private Insurance Questions

Can I itemize medical deductions on my federal tax return if I already received reimbursement for those expenses from the health care flexible spending account?

No. That is considered double dipping by the IRS. You can have a health care FSA and take an itemized deduction for medical expenses, but you cannot claim an itemized deduction on your federal income tax return and receive a reimbursement from your health care FSA for the same medical expense. You should speak with a tax consultant on what would be the best option for you.

How can drug trials affect health insurance coverage? I have the opportunity to be involved with a subcutaneous immunoglobulin (SCIG) trial, but want to make sure I have coverage.

You should remain insured while on a clinical drug trial. A clinical drug trial will only pay for what the trial is intended to do; in this case, you may be receiving your SCIG free for a certain amount of time. Keep copies of the study to show that you had been receiving treatment. You may be able to get a copy of the study from As long as you have been receiving treatment for your condition, the insurance company does not have good cause to deny coverage… just make sure to keep good records!

I have a PPO health insurance plan through my employer. If I see a nonparticipating provider, does that mean that I may be paying more out-of-pocket? What exactly does that mean?

Yes, in most cases you will be paying more money out-of-pocket to see a nonparticipating provider. A PPO Plan, or a Preferred Provider Organization, is a type of managed care coverage based on a network of doctors and hospitals that provides care to an enrolled population at a prearranged discounted rate. PPO members usually pay more when they receive care outside the PPO network. If you decide to see a nonparticipating provider, you should know the out-of-network benefits. Your share of the cost would be the out-of-network deductible, plus the coinsurance amount, plus the balance billing amount.

What is the balance billing amount? This is the difference between the billed amount and the contracted amount. For example, your doctor bills $500 for a service, however your insurance contracted amount (or allowed benefit) is $250. Assuming that your deductible has been satisfied and you have a 70%/30% PPO Plan, your out-of-network benefit pays 70% of the $250. So, you would be responsible for 30% of the $250 contracted amount which is $75. Add the balance billing amount of $250 and your total out-of-pocket payment is $325.

I have my health insurance through my employer. The deductibles and coinsurance have increased effective January 1 of next year. My immunoglobulin is going to cost a lot more out of pocket – what are my options?

First, make sure you get a copy of the summary plan description (SPD). The SPD provides a wealth of information — your health plan administrator should provide a copy. It outlines your benefits and your legal rights under the Employee Retirement Income Security Act (ERISA), the federal law that protects your health benefits.

Second, if your policy contains a “Case Management” benefit, call the member services line on the back of your insurance card and ask to be connected with a Case Manager. What do Case Managers do? They work for the insurance company. Their role is to explore your benefits and to get the best “benefit” out of your health insurance. They try to keep your costs down, which keeps the insurance company’s costs down.

What questions should you ask? First, explain to them what you are looking to do: you have been receiving immunoglobulin at the same site for years, but now your out-of-pocket costs have increased. Explain to them that you are looking to decrease your out-of-pocket costs. You would like to know, what your insurance pays if you receive your immunoglobulin:

A.) At a doctor’s office

B.) At an outpatient infusion site

C.) Through Home Healthcare

D.) Intravenous administration vs. subcutaneous administration

Finally, call a Home Healthcare company that provides immunoglobulin therapy and explain your situation. See if they offer any financial assistance programs. They will first take your insurance information to “do an insurance check”. This typically takes 48 hours. If you qualify for a financial assistance program, they will send you an application. However, they usually do not send the application unless you go on service with them. So make sure you are clear that you are exploring all your options before making a decision with your doctor.

Once you have done your homework and looked at all the avenues, take this information, including the different sites of care, mode of administration and monthly out-of-pocket costs, to your next doctor appointment. Sit down with your immunologist to discuss the different treatment options.

I hear that many primary immunodeficient patients are having problems with their health insurance. Luckily, I am curently not having any problems receiving my immunoglobulin, but is there anything I should do to prepare in case my insurance starts to question my use of IVIG?

This is a great question- one that may help many others. First of all, you have to be your own advocate. Request copies of all your medical records. Keep a copy of your blood work, prior to going on immunoglobulin replacement therapy and any medical records that document your history of severe infections, hospitalizations, etc. You can track all of this in the IDF eHealthRecord. Also, if possible, individuals with a primary immunodeficiency should be seeing an immunologist that sees many patients with the same insurance problems you may someday face. Chances are, since they have run into these issues already, they know how to work with the insurance companies.

My doctor no longer participates with my insurance company. When I made my appointment, he was still a participating provider, but he just cancelled his contract with them last month. I had no knowledge of this until I received a huge bill in the mail today from my doctor – Help!

The provider should have mentioned this to you when you walked into the appointment on the day of service. However, since that did not happen, you should first call your provider’s billing office and explain this situation. Be sure to give them the facts, such as, you have been a patient for X amount of years, you have your insurance through “ABC Insurance Company”, and that you were unaware that your doctor no longer participated with your insurance. Ask them what they suggest to do. During the phone call, be sure to write down whom you are speaking with, the phone number, the date and what was discussed. If this discussion does not help, you can appeal this decision.

Your Appeals and Grievance rights should be on the denial letter from the insurance company or in your Summary Plan Description. Read your rights carefully and do exactly what they tell you. Include the information that they request. It is also a good idea to print off your insurance claim history online with this provider. This will show how many times you have seen this provider and that your insurance company had been paying for the services.

The Appeals Department reviews thousands of cases, so keep it simple and do not become emotional. You want to be straight and to the point in your appeal letter. Finally, ASK them for what you want. For example, in this case, end your appeal with “As you can see from the information I provided, I am asking you to overturn this denial and pay this claim. Thank you for your consideration. I look forward to hearing from you within 30 days.” Depending on the contract terms of agreement between the insurer and your provider, they will base their decision to your appeal.

TIP for the future: On the day that you make an appointment with the provider, go to your insurance company’s Website and print off your provider’s information. The printout should be dated and include your insurance company’s Website. This shows your due diligence in ensuring that you are using participating providers and it gives you a leg to stand on if you ever need to appeal. You will have hard copy proof that the day you made the doctor appointment, according to “ABC Company’s Website”; your physician was a participating provider.

My husband and I are both offered health insurance through our employers. How do we choose the right one for us?

IDF created the IDF Health Insurance Toolkit to help patients choose insurance plans. For a comprehensive look at how to pick insurance plans go to IDF's Patient Insurance Center.

Here are some general guidelines that might help you when comparing the two benefit plans:

  • What are the monthly employee contribution levels?
  • How much is the annual deductible?
  • How much is the Out of Pocket Maximum?
  • What is the coinsurance amount (percentage of costs) after the deductible has been satisfied?
  • What is the copayment (flat dollar amount) for services such as doctor office visits?
  • What is not covered by the policy? Look for the exclusions.
  • What is the Home Health Benefit? Are nursing services and supplies associated with infusion covered?
  • Is the Prescription Benefit included in the deductible? Does it have its own Deductible? What are the copays?
  • Do your doctors participate with your plan?
  • Is the plan a HMO, POS, or a PPO?
  • Will the policy cover intravenous (IVIG) or subcutaneous (SCIG) treatment?
  • Does the policy cover dependents and spouse/domestic partner? Until what age or event?
  • Pull your Explanation of Benefits (EOBs) from the previous year. Look to see how you and your family used the health benefits and compare those benefits too.
  • Call your doctor’s office and speak with the billing department – ask them what insurance companies cause them less headaches.

After you have gathered all this information, you should have a clearer picture of what insurance plan is the better choice for you and your family.

My husband and I work and are both covered under our own health insurance policies through our employers. My open enrollment is in January and my husband’s is in July. Would I be able to cancel my insurance and go onto his insurance in July? I was told that I cannot make any changes to my insurance for 12 months.

As long as the Health Insurance Plan Document states that you are eligible for coverage under your husband’s employer’s plan, you can drop your insurance effective June 30th and go onto your spouse’s insurance plan effective July 1st.

I would suggest that you speak with your Human Resources Department and make them aware of your plans. You must notify your employer within 31 days of a qualifying event (i.e. July 1st) in order to cancel your current health insurance coverage.

The end of the year is fast approaching and I still have funds available in my health Flexible Spending Account (FSA). Am I correct that if I do not use the funds I will lose it? If so, how can I use up the remaining balance?

It is always best to keep track of your out of pocket medical costs so that you can appropriately contribute to your health Flexible Spending Account (FSA) because – YES it is a use it or lose it account. In the past many people would use up their funds at the end of the year by stocking up on over-the-counter items such as ibuprofen, acne products, or antacids. However, you need to be aware that these items do not necessarily qualify for reimbursement.

Effective January 1, 2011, distributions from your health FSA are allowed to reimburse over-the-counter medicines only if they are purchased with a prescription. The prescription, or a copy of it, must be submitted with the receipt in order to be reimbursed. This new rule does not apply to over-the-counter medical devices such as crutches, bandages, or diagnostic devices (ex. blood sugar test kits). So if you are in need of these items – stock up! Otherwise, if you have any doctor’s visits that need to be scheduled try to get in before the end of the year. You can submit those co-pays for reimbursement.

What do you think of high deductible health insurance plans?

It depends on your own personal circumstances.

Most insurance companies offer high deductible plans. The rationale of these plans is to offset the high premium increases that many employers and employees are facing. If you think you can afford to pay out of pocket for care that is subject to the deductible, since the deductible needs to be satisfied before the insurance kicks in, this might be a reasonable alternative for you. Just be sure to read the policy carefully.

In addition to the deductible, you need to be familiar with other cost sharing requirements, such as the out of pocket maximum, what services are covered or excluded, pharmacy benefit (check to see if it is subject to the same deductible or has a separate deductible), office visits, home healthcare, inpatient hospitalization, outpatient hospitalization, and so on.

What is a “Domestic Partner Coverage” policy? My boyfriend and I live together, so can I drop my individual insurance policy and go on his employer’s insurance?

The first step is to find out if “Domestic Partner” benefits are available under his employer’s policy. Domestic partner benefits are benefits that an employer chooses to offer to an employee’s unmarried partner, whether of the same or opposite sex. Private employers are not required to offer health insurance to any employees, including domestic partners. Employers that choose to offer health benefits must follow federal law and state law, when applicable.

The second step is to read the eligibility definition and see if you qualify. Employers sponsoring group health insurance plans for their employees define the policy’s eligibility criteria. When they purchase a policy from an insurance company, the eligibility requirements are specifically stated in the policy. Thus, whether opposite-sex domestic partners are eligible under the policy is determined by the employer. Employers may extend their eligibility to include domestic partners; some limit it to same-sex partners while others extend it to both same-sex and opposite-sex partners.

The third step is to make sure you have the documentation needed for the employer. An employer that offers benefits to the domestic partner creates a definition of what an eligible domestic partner is. The most common definitions include the following: 1) the partners must be at least age 18; 2) neither person is related by blood; 3) the partners must be in a committed relationship; 4) the relationship must be exclusive; 5) the partners must be financially interdependent. Documentation of proof of a domestic partner relationship can take many forms and it is the responsibility of the employer to determine what is appropriate. Some employers are satisfied with the partners signing an affidavit of their relationship. Some employers may require proof of some financial relationship, such as a joint lease or mortgage.

When can I start using my healthcare flexible spending account?

You can access your entire year’s worth of contributions at the start of your employer’s benefit plan year. For example, if your employer’s benefit year starts on January 1, you could get your child’s braces on January 2nd and be reimbursed for the entire out-of-pocket amount right away, before the year’s entire payroll deductions have been made.

Medicare/Medicaid and Other Government Subsidized Health Plans

I am on Medicare and my home healthcare company just told me that my IVIG would be covered under Part D and not to worry. I just received my Summary Notices from Medicare stating that my IVIG had been denied!

If you have a primary immunodeficiency disease with any of the diagnosis codes 279.04, 279.05, 279.06, 279.12, and 279.2, your IVIG treatment is reimbursed under Medicare Part B. If your home healthcare company submits the IVIG service claim under Part D, it will be denied, because IVIG for primary immunodeficient patients is not covered under Medicare Part D. Your home healthcare company will have to reprocess and submit those IVIG claims to the Medicare Part B carrier.

In some cases, a Medicare Advantage plan may cover other primary immunodeficiency disease diagnosis codes under Part D. You should check with your Medicare Advantage provider to see how they are processing your claim.

I have Medicare because I was approved by the Social Security Administration. My husband and I also have health insurance through his employer. Which insurance is primary?

If your husband’s employer has 100+ employees (large group), the employer sponsored group plan would be primary and Medicare would be secondary.

Sometimes employers with fewer than 100 employees join other employers in a multi-employer plan. If at least one employer in the multi-employer plan has 100 employees or more, then Medicare is the secondary payer for disabled Medicare beneficiaries enrolled in the plan, including those covered by small employers.

For example: Henry works 37.5 hours (full-time) for ABC Company, which has 250 employees. His wife Sara is 41 years old & is disabled. Henry and Sara are enrolled in the ABC Company’s group health insurance. Sara also has Medicare because of her disability. ABC Company’s group insurance would be Sara’s primary insurance; Medicare would be secondary.

I will be turning 65 at the end of the year, and I am trying to understand Medicare coverage. I have CVID and do subcutaneous Ig therapy. Will this be covered and what is my best option?

There are many options when it comes to Medicare coverage, and you will have to do a little investigative work to determine what is going to work best for you.

Your subcutaneous therapy will be covered under the traditional Medicare Part B medical benefit. This is only covered at 80% so you will want to look into getting a supplemental/medigap plan to cover the remaining amount.

Another option is a Medicare Advantage plan (Part C). These plans are sold as an “all in one policy” and act more like a private insurance. According to Medicare regulations, the managed care plans must provide enrollees with all Part A and Part B benefits. Medicare Advantage plans are not required to provide enrollees the same access to providers that is provided under original Medicare.

The cost for your treatment is dependent upon the plan design. You could have a flat $20 copay, or you could be responsible for a percentage of the cost (co-insurance). Over the past few years, patients with Medicare Advantage plans have reported to IDF that most have a 20 to 30% coinsurance for treatment!

Unfortunately most of these patients picked the Medicare Advantage plan thinking it acted the same as traditional Medicare Part B and a secondary plan. It is important to keep in mind that if you choose an advantage plan, you are not eligible to obtain a secondary policy. Make sure you know the coverage before enrolling!

Since Medicare plans vary from state to state and even by counties within a state you need to research what plans you are eligible for. You can contact your state’s SHIP program as they have trained counselors who can tell you the plans you are eligible for and assist you in finding the answers to your questions regarding coverage. To find your state’s SHIP program contact information, go to Seniors Resource Guide.

  • Make sure you do a thorough plan comparison to determine what will work best for you. Information to know before purchasing a plan:
  • What is my out of pocket maximum?
  • Do I have a deductible?
  • Is my deductible included in the out of pocket maximum or is it in addition to the maximum?
  • How is immunoglobulin covered?
  • Do I have a coinsurance or a flat co-pay?
  • Do I have options for site of care?
  • Are there out-of-network benefits?

Once you have the details of your plan options, you can make an informed decision on what will work best for you. Download the IDF Health Insurance Toolkit as it has helpful information and comparison worksheets to help you do this.

Medical Insurance

Can I itemize medical deductions on my federal tax return if I already received reimbursement for those expenses from my healthcare flexible spending account (FSA)?

If you did not have a FSA, you would be able to claim certain medical expenses as deductions on your taxes. However, since you do have an account, taxes were never taken out of your FSA contributions. For that reason, medical expenses paid for with FSA money cannot be included on your tax return. You should speak with a tax consultant when determining what expenses are eligible for deduction.

Is IVIG or SCIG treatment covered under Medicare Part B or Part D?

If you have a primary immunodeficiency disease with the diagnosis codes 279.04, 279.05, 279.06, 279.12, or 279.2, your IVIG/SCIG treatment is reimbursed under Medicare Part B. If your provider submits the IVIG/SCIG service claim under Part D, it will most likely be denied. Your provider will have to reprocess and submit those IVIG/SCIG claims through Medicare Part B.

In some cases, a Medicare Advantage plan may cover other primary immunodeficiency disease diagnosis codes under Part D. You should check with your Medicare Advantage provider to see how they are processing your claim.

What are some of the important health care reform changes that have already gone into effect as a result of The Patient Protection and Affordable Care Act (PPACA)?
  • Adult children may remain as dependents on their parents’ policy until their 26th birthday.
  • Children under age 19 may not be excluded for pre-existing conditions.
  • No more lifetime or annual caps on health coverage.
  • Free preventative care for all people.
  • The “doughnut hole” is in the process of closing for Medicare patients, making prescription medications more affordable for seniors.
  • Insurance plans are available for persons who have not been able to purchase medical insurance because of a pre-existing condition.
What are some tips for applying for Social Security Disability?
  • When filing a claim, it is best to obtain the most current records from your relevant treating sources, for example, your immunologist, rheumatologist, etc., and submit them at the time of the application. This will help expedite your claim. You should also obtain letters from your treating physician and other specialists with supporting objective evidence such as lab findings, MRIs, x-rays, etc stating that you are unable to sustain a 40 hour workweek. This will greatly support your claim.
  • Stay in contact with your disability examiner every 10-14 days. Their name and phone number should be located on the mail they send to you. Ask them if they have received all your pertinent medical records. Most hospitals and physicians’ offices rely on copy services which only come by once a week. It may take several phone calls/faxes to obtain the needed information which could make a huge difference in your claim.
  • When Disability Determination Services (DDS) sends you forms to complete regarding how pain affects your activities, fatigue, etc you should be as detailed as possible and don’t be afraid to add extra sheets to the forms. Describe a typical day when completing an activity of daily living form. You will also be asked to complete a work history form. This should include the jobs you worked in the last 15 years. Please be as detailed as possible regarding your job duties, rate of pay, supervisory duties, etc.
  • You may be asked to attend a medical exam at no expense to you to in order to obtain more information. This is more common in cases such as rheumatoid arthritis, SLE, fibromyalgia etc when detailed joint range of motion and mobility/gait information is needed in addition to the information about your PIDD. It is very important that you keep this exam. Your disability examiner will contact you by phone or mail regarding the details of the exam.

For more detailed information, please go to the Social Security Administration Website.

What are some tips for dealing with an insurance denial for my immunoglobulin (IG) replacement therapy?

Below are some “how to” tips from a clinical immunologist that has been successful in overturning IG denials. This is followed by a link to the IDF website that includes additional information including sample appeal letters that should be tailored to the patient’s clinical history.

The appeal should be short, succinct and carefully documented.

  • Keep in mind that you have 2 minutes of the Medical Director’s attention.
  • Provide well-accepted diagnostic studies which are in the practice guidelines.
  • Provide standards of practical criteria to support the laboratory studies.
  • Provide proof and documentation of serious infections/complications which have not been responsive to appropriate medical/surgical intervention; including clear radiographic evidence of persistent disease, e.g. lungs, sinuses et al, clinical documentation of infections etc.
  • Focus on the rationale for immunoglobulin therapy – a doctor’s letter that states “because it is medically necessary” is not specific enough to be added to an appeal letter. Precise statements are required. . . for example: 3 episodes of pneumonia with fever to 102. Chest x-ray (if available) showed lobar pneumonia and xx days of antibiotics were required.
  • Keep in mind that the insurance companies are reviewing thousands of appeals; therefore, the larger packets, will be put to the side. The shorter the appeal, the shorter the turn-around-time for a response.
  • When concluding the letter, add the names of the immunologists that have completed the scientific research on the diagnosis in question, should the insurer request a peer review. For example “Should you have any questions, I would request a peer review by either Dr. John Smith or Dr. Ann Jones from the University School of Medicine”

Click here for more information to share with your healthcare professional.

What is a POS?

POS is a Point-of-Service Plan. It is a type of managed care plan that is an HMO with an out of- network option. You can decide whether to go to a network provider and pay a flat dollar or to an out-of-network provider and pay a deductible and/or a coinsurance charge.

What is a PPO?

A PPO Plan, or a Preferred Provider Organization, is a type of managed care coverage based on a network of doctors and hospitals that provides care to an enrolled population at a pre-arranged discounted rate. PPO members can use doctors outside of the network but they will usually pay more when they choose to go outside the PPO network. If you decide to see a nonparticipating provider, you should know the out-of-network benefits. Your share of the cost would be the out-of-network deductible, plus the coinsurance amount, plus the balance billing amount.

What is the balance billing amount? This is the difference between the billed amount and the contracted amount. For example, your doctor bills $500 for a service, however your insurance contracted amount (or allowed benefit) is $250. Assuming that your deductible has been satisfied and you have a 70%/30% PPO Plan, your out-of-network benefit pays 70% of the $250. So, you would be responsible for 30% of the $250 contracted amount which is $75. Add the balance billing amount of $250 and your total out-of-pocket payment is $325. To minimize your out-of-pocket expenses, it is important to try to see a participating provider in your plan’s network.

What is an HMO?

HMO is a Health Maintenance Organization. As a member of an HMO, you select a primary care physician from a list of doctors in that HMO’s network. Your primary care physician will be the first medical provider you call or see for a medical condition. He or she will make any needed referrals to a medical specialist. Typically, these specialists will be part of the HMO network. If you obtain care without your primary care physician’s referral or obtain care from a non-network member, you will be responsible for paying the entire bill. Normally HMOs have a co-payment for the visit or service. This is the most restrictive type of plan.

What is an Indemnity Plan?

An Indemnity Plan is commonly known as a fee for service or traditional plan. If you select an Indemnity plan you have the freedom to visit any medical provider. You do not need referrals or authorizations; however, some plans may require you to precertify for certain procedures. Most indemnity plans require you to pay a deductible. After you have paid your deductible, indemnity policies typically pay a percentage of “usual and customary” charges for covered services; often the insurance company pays 80% and you pay 20%. Most plans have an annual out of pocket maximum and once you’ve reached this they will pay 100% of all “usual and customary” charges for covered services. Many health insurance companies have moved away from indemnity plans. This is the least restrictive, therefore the most expensive type of health plan.

What is COBRA?

COBRA, the Consolidated Omnibus Budget Reconciliation Act, gives workers who lose their health benefits the right to choose to continue group health benefits provided by their plan under certain circumstances.

The employer will send an election notice within 14 days after the employee’s last day on the health insurance plan. The employee will then have 60 days to decide whether to elect COBRA continuation coverage. The employee will then have 45 days after electing coverage to pay the initial premium. Expect to pay the total premium (the employer + employee contribution) plus 2% for administration. Also, another important note is that the premiums are not tax deductible, like they are when they are deducted from payroll.

There are certain qualifying events that would cause an individual to lose health coverage. The type of qualifying event will determine who the qualified beneficiaries are and the amount of time that a plan must offer the health coverage to them under COBRA. A plan, at its discretion, may provide longer periods of continuation coverage.

Qualifying Events for Employees

  • Voluntary or involuntary termination of employment for reasons other than gross misconduct
  • Reduction in the number of hours of employment

Qualifying Events for Spouses

  • Voluntary or involuntary termination of the covered employee’s employment for any reason other than gross misconduct
  • Reduction in the hours worked by the covered employee
  • Covered employee’s becoming entitled to Medicare
  • Divorce or legal separation of the covered employee
  • Death of the covered employee

Qualifying Events for Dependent Children

  • Loss of dependent child status under the plan rules
  • Voluntary or involuntary termination of the covered employee’s employment for any reason other than gross misconduct
  • Reduction in the hours worked by the covered employee
  • Covered employee’s becoming entitled to Medicare
  • Divorce or legal separation of the covered employee
  • Death of the covered employee
What is HIPAA?

The Health Insurance Portability and Accountability Act, better known as HIPAA, amended the Employee Retirement Income Security Act (ERISA) in 1996, to provide new rights and protections for participants and beneficiaries in group health plans. Understanding this amendment is important to your decisions about future health coverage.HIPAA includes protections for coverage under group health plans that:

  • Limit exclusions for pre-existing conditions;
  • Prohibit discrimination against employees and dependents based on their health status; and,
  • Allow a special opportunity to enroll in a new plan to individuals in certain circumstances.

HIPAA requires that group health plans give credit for prior coverage. You will receive credit for previous healthcare coverage, as long as you do not have a break in credible coverage of 63 or more days. This is called credible coverage. COBRA coverage also counts as credible coverage as long as you do not have a break in coverage of 63 or more days between COBRA coverage and the group health insurance plan.

In other words, as long as you do not go without insurance for 63 days or more, the insurance company cannot enact the pre-existing condition clause. It is important for you to know your benefits and to understand if your treatment needs to be preauthorized by your provider before rendering services.

For additional information on the HIPAA, go to the Department of Labor’s Employee Benefits Security Administration at

What is the difference between co-pay and a coinsurance?

A co-pay requires the insured to pay a specified amount of out-of-pocket expenses for health care services such as doctor visits and prescriptions drugs at the time the service is rendered, with the insurer paying the remaining costs. Co-pay fees will vary among insurers but are typically very affordable. For example, a co-pay plan may require the insured to pay $25 per doctor visit or $10 per prescription up to a specified coverage limit.

With a coinsurance, a health plan will require you to pay a percentage rate meaning that you will essentially be splitting the cost of your healthcare with the insurance carrier. For instance, if the health plan has an 80/20 coinsurance rate, the insurance plan pays for 80% of the eligible medical expenses and you are responsible for the remaining 20%.

What is the difference between Group Health Insurance Plans and Individual Health Insurance Plans?

Group health insurance is a policy that is purchased by an employer and offered to eligible employees as a benefit of working for that company. Federal law mandates that no matter what health conditions members may have, no individual employee can be turned down by an insurance company for group coverage. This requirement is known in the insurance industry as “guaranteed issue.” Group insurance companies are also required to give employees credit for prior coverage against any pre-existing condition waiting period that may be imposed, as long as the employee had other health insurance coverage within 63 days of the application for new coverage.

Individual health insurance is different from group health insurance. The laws that mandate the types of services that must be included in individual policies are often different than those for group policies. Benefits of individual plans are generally less extensive than group plans. Benefits are often simpler and deductibles and co-insurance are generally higher in individual policies.

Individual health insurance companies are more limited than group insurance companies in their ability to spread risk, so this means that applicants will need to complete a brief health questionnaire when applying for benefits. Unlike group insurance companies, individual health insurance companies can decide not to cover people with serious medical conditions, deeming them “uninsurable.” The laws concerning individual health insurance differ from state to state.

What questions should I ask before selecting a new insurance plan?

IDF created the IDF Health Insurance Toolkit to provide you with information, facts, resources and worksheets to help you choose the best possible options for you and your family. You can find a complete list of questions to ask before selecting a health insurance plan from the IDF Health Insurance Toolkit.

Some items to consider

  • Will the policy cover intravenous (IVIG) or subcutaneous (SCIG) immunoglobulin treatment?
  • Are there particular locations that I have to get my treatment? Do they differ based on whether it is SCIG or IVIG?
  • Can I get my IVIG done at home?
  • Is there an annual deductible? If so, how much is it?
  • Is there a co-pay or co-insurance that must be paid for IVIG or SCIG treatment? If so, how much or what percentage?
  • What is my maximum out of pocket expense each year? (In other words, what is the most I will have to pay each year?)
  • Is there a waiting period before a pre-existing condition or illness will be covered and services paid for? If so, how long? Also, can it be waived?
  • Will the policy allow for use at both an “in-network” and “out-of-network” provider, physician, and pharmacy? If so, what are the differences in cost?