Private and Public Payers

Keep in mind that you have many different options. There are several types of commercial insurance. Federal and state governments also fund coverage. And there are additional resources in place to protect you, such as the Health Insurance Portability and Accountability Act (HIPAA) and COBRA.

Remember, too, that one of the benefits of enrolling in the GARDian program is that you can call and speak to a GARDian Program Specialist who can help you sort it all out. Here’s a brief overview to help you get started.

Private/Commercial Insurance^1,2

Whether you have insurance through your employer or through an individual policy, plans vary. Most insurance plans offer you a choice of coverage based on your ability or willingness to pay in the form of premiums, out-of-pocket expenses, deductibles, and co-pays.

Group vs. Private

The major difference between group and individual health insurance involves evidence of insurability.

Individual plans may require a health questionnaire and a medical examination. An insurer may decline coverage on the basis of the applicant’s personal habits, health, medical history, age, income, or any other factor that affects risk acceptance. Or the insurer may issue a policy with limitations on coverage. Children under age 19 cannot be denied a policy due to a pre-existing condition.

Most group insurance is issued without medical examination or other evidence of individual insurability, because the insurer knows that it can cover enough individuals to balance those in poor health against those in good health.

Types of Commercial Insurance

• Health Maintenance Organizations (HMOs): Members pay fixed, periodic fees and in return receive healthcare services as often as needed. Based on medical needs, your primary care provider (PCP) refers you to other services in the network. In order to not pay 100% out-of-pocket for your care, you must stay within the network of providers.
• Preferred Provider Organizations (PPOs): Provide care by contracting with a network of doctors, dentists, hospitals or other healthcare service providers at prearranged rates or discounts. Members have more care options, but need to reach a certain deductible before insurance pays any bills.

Medicare^3,4

Medicare is financed by the federal government and provides benefits to individuals older than 65, as well as younger people who meet specific disease/disability criteria.

Medicare Part A

• When you sign up for Medicare, you automatically get Part A
• Part A covers hospital rooms, meals, nursing services, hospice care, and home healthcare
• Most people will not have to pay a monthly cost or premium, because they or their spouse paid Medicare taxes while working

Medicare Part B

• Supplemental insurance for people who qualify for Medicare
• Covers doctor visits, laboratory tests, X-rays, physical therapy, rehabilitation, ambulance, some home healthcare, and various medical equipment and supplies when medically necessary
• You must sign up for Medicare Part B and may have a monthly premium and yearly deductible. For approved services and supplies, you are responsible for a 20% co-pay.
• The premium cost increases each January, and if you do not sign up for Medicare Part B when you are first eligible, you may have to permanently pay a higher monthly premium.

Medicare Part C

• Medicare Advantage Plans (lHMOs and PPOs) are sometimes referred to as Medicare Part C
• These are private Medicare-approved plans that provide all your Part A (hospital) and part B (medical) coverage. They must cover medically necessary services
• Generally they offer extra benefits, and many include Part D drug coverage. You may have to see the plan’s in-network doctors and go to certain hospitals to get care
• These plans can save you money, since out-of-pocket costs are often lower than with Medicare alone. However, cost varies by the services you use and the type of policy you purchase.

Medicare Part D

• You must be enrolled in Medicare before you can apply for Part D coverage
• Part D supplies prescription drug coverage
• Most people will pay a monthly premium for this coverage
• Part D may help you lower prescription drug costs and protect against higher costs in the future
• You choose the drug plan and pay a monthly premium
• Not all prescription drugs are covered under Medicare Part D, so make sure you have a good understanding of each plan’s coverage and benefits
• If you decide not to enroll in a drug plan when first eligible, you may pay a penalty if you decide to join later

Medicaid5

Medicaid is a federal and state-funded health insurance program for low-income parents, children, seniors, and people with disabilities who cannot afford healthcare. Medicaid may help pay for certain medical expenses such as:

• Doctor and hospital bills
• Prescriptions (excluding prescriptions for Medicare beneficiaries)
• Vision and dental care
• Medicare premiums
• Nursing home care, Personal Care Services (PCS), medical equipment, and other home health services
• In-home care under the Community Alternatives Program (CAP)
• Mental healthcare
• Most medically necessary services for children younger than 21 years

Medicaid is a state-administered program, and each state sets its own guidelines regarding eligibility and services.

Certain requirements must be met, which may include age; whether you are pregnant, disabled, blind, or aged; your income and resources (like bank accounts, real property, or other items that can be sold for cash); and whether you are a US citizen or a lawfully admitted immigrant. There are special rules for those who live in nursing homes and for disabled children living at home.

In most states there are two types of programs: Traditional Medicaid, referred to as Fee-for-Service Medicaid, and Medicaid Managed Care. The main difference is whether or not you are able to choose your own healthcare provider or must stay within a contractual network.

If you’re eligible for Medicaid, you should check on the availability of your brand of IgG treatment.

Sources:

1. Health maintenance organization plans page. MedHealthInsurance website. http://www.medhealthinsurance.com/hmoplan.htm. Accessed May 4, 2011.
2. Preferred provider organization plans page. MedHealthInsurance website. http://www.medhealthinsurance.com/ppoplan.htm. Accessed May 4, 2011.
3. Centers for Medicaid and Medicare Services page. Medicare website. http://www.medicare.gov/Publications/Pubs/pdf/10128.pdf. Accessed May 4, 2011.
4. Medicare At-a-Glance page. Medicare website. http://www.medicare.gov/Publications/Pubs/pdf/10050.pdf. Accessed May 4, 2011.
5. Medicaid At-a-Glance page. Centers for Medicare and Medicaid Services website. http://www.cms.gov/MedicaidDataSourcesGenInfo/downloads/maag2005.pdf. Accessed May 4, 2011.