Q: What are some important terms to know regarding insurance?

Out-of-Pocket Costs - Costs paid “out of your own pocket”; costs not covered by your insurance that you are in charge of personally paying for.

Premium - An amount of money paid to the insurance company in order to keep your plan active. Payment periods may be monthly, quarterly, semi-annual, or annual. Not paying premiums will result in loss of coverage.

Deductible - The amount of money you must pay out of pocket before your insurance starts paying for covered expenses. It is usually a set amount that resets at the start of each policy period.

Co-Payment - A fixed numerical amount that is paid out of pocket for a health service, such as a doctor’s visit. For example, you may pay $30 every time for a doctor’s visit, and your insurance covers the rest of the total, no matter how much. These are paid even after meeting your deductible. It is a kind of cost-sharing agreement between you and your insurance company. 

Co-Insurance - A fixed percentage amount that is paid out of pocket for a health service, such as a doctor’s visit. For example, if you were responsible for 30% of the bill while your insurance covered the other 70%, you would pay $30 if the visit was $100 total, pay $60 if the visit was $200 total, etc. These are paid even after meeting your deductible. It is also a kind of cost-sharing agreement between you and your insurance company.

Claim: The process by which the healthcare provider submits a request for reimbursement from the patient's insurer. This typically includes the cost of the medication, the service provided (administration, monitoring), and other associated fees. Once the insurer processes the claim, they reimburse the provider according to their policy terms.

Q: What are the main differences between BCBS, UHC, Superior HealthPlan, and Cigna in Texas?

• BCBS: Large provider network, flexible plans, and nationwide presence. Blue Cross and Blue Shield of Texas is the biggest healthcare provider in Texas. 

• UHC: The largest healthcare insurance company in the United States and offers nationwide coverage, good for frequent travelers.

• Superior HealthPlan: Affordable options for underserved communities, including Medicaid/CHIP. The exclusive provider for STAR, a Medicaid program for individuals under the foster care system. 

• Cigna: Strong specialist network, good for chronic conditions. Includes plans with no cost for telehealth and prevention care. 

Q: How do Employer-sponsored Healthcare Plans compare to Individual Healthcare Plans? 

Employer-sponsored Healthcare Plans allows employees to benefit from group rates which are generally lower than individual market rates. Additionally, employers can subsidize a significant portion of the premium, further lowering the cost of the healthcare plan. A downside of employer-sponsored plans is the limitation of options: employees do not have control over the insurer or the in-network provider, and the coverage is not tied to the individual but to the employment. 

Q: What is a self-insured business plan, and how does it work?

A self-insured plan is when a business pays for employees' healthcare costs directly instead of using an insurance company. It can reduce costs for employers but requires managing healthcare expenses internally.

Q: What Insurance Plan Would be Right For Me?

There are several different types of insurance plans to choose from. Listed are the 4 most popular insurance plans, including Preferred Provider Organization (PPO), Health Maintenance Organization (HMO), Point of Service Plan (PPO), and Consolidated Omnibus Reconciliation Act (COBRA). Weigh the general benefits and drawbacks to each plan below:

Preferred Provider Organization (PPO)

• Higher premium monthly plans

• Don’t Need to Choose a PCP

• Flexibility to use providers both in and out of network without a referral

• Out-of-pocket medical costs can also run higher

• In or Out of Network

• May need to file claims

Health Maintenance Organization (HMO)

• May choose a PCP

• Lower premium monthly pans

• Does not cover out of network

• Smaller network

• Primary Care Physician → Referral → Specialist

• No need to file claims

Point of Service Plan (POS)

• Provides both in-network and out-of-network benefits but requires that you choose a primary care provider (PCP) and get referrals to see specialists

Uninsured Plans

• Consolidated Omnibus Budget Reconciliation Act (COBRA)

  • Allows individuals and their families to continue their group health insurance coverage for a limited time after a qualifying event, such as job loss, reduction in work hours, or other life events

  • https://www.cobrainsurance.com/

Q: What is Medicare, and what do I need to know about Medicare?

Medicare is a federal health insurance program for people who are 65 and older and some younger individuals with disabilities or specific conditions. Costs vary by plan. There are multiple parts of Medicare. Parts A and B are run by social security while Parts C and D are run by private companies with government approval. A breakdown of the parts include:

• Part A (Hospital Insurance): This covers inpatient care at hospitals, skilled nursing facilities, hospices, and some home health services. Part A is free if you have worked and paid into Medicare tax for 10+ years. You can sign up for Part A alone or in conjunction with Part B.

• Part B (Medical Insurance): This covers outpatient care, doctor visits, home health care, medical equipment, and some preventative care. There is typically a monthly premium and deductible based on income level.

• Part C (Medicare Advantage Plans): This includes alternative, private insurance plans that combine Parts A, B, and often D. They usually offer additional benefits like dental, vision, and hearing. It is important to note that you cannot have both an Advantage and Medigap policy at the same time; it is either or. 

• Part D (Prescription Drug Coverage): This covers prescription drugs. You must sign up for Part A or Part B in order to enroll in Part D.

Enrollment Process: There are several ways you can enroll in Medicare, and some are time-sensitive:

• Initial Enrollment:

  • The Initial Enrollment Period (IEP) is for when you first qualify. It starts three months before your 65th birthday and ends three months after.

  • You will be enrolled automatically in Parts A and B if you are already receiving other Social Security benefits. If not, you need to apply through the Social Security Administration (SSA):

    • Online: Create an account and enroll online at ssa.gov

    • Phone: Call 1-800-772-1213 to get real-time assistance with the application process with a live agent.

    • In-Person: Visit a local Social Security office to complete an application in person.

• Special Enrollment:

  • The Special Enrollment Period is for if you are still working and have employer coverage at age 65. In this case, you may qualify to sign up after the initial enrollment period without penalties.

• General Enrollment:

  • The General Enrollment Period is for those who missed their initial period and runs from January 1 – March 31 each year. Coverage starts July 1, but late penalties may apply.

• Medicare Advantage & Part D Enrollment:

  • You must first be enrolled in Parts A & B before signing up.

  • You can join a Medicare Advantage or Part D plan during:

    • Initial Enrollment Period

    • Annual Open Enrollment / General Enrollment

    • Special Enrollment (if you qualify)

Renewal and Continuous Coverage: Medicare automatically renews every year. There is only manual work on the patient end if you want to make changes to your plan.

Q: What is Medicaid, and what do I need to know about Medicaid?

Medicaid is a joint federal and state program that provides particular individuals with free or low-cost healthcare based on factors such as income and household size. Eligibility and criteria vary by state. Here are the Medicaid details for Texas:

Eligibility:

• • Children: Uninsured children who are 18 or younger may qualify for Children's Medicaid or the Children's Health Insurance Program (CHIP) if specific low-income requirements are met.

  • Pregnant Women: Pregnant women may qualify during pregnancy and up to two months postpartum if specific low-income requirements are met.

  • Parents and Caretakers: Parents/caretakers of children younger than 19 may qualify if specific income requirements are met.

  • Seniors and Individuals with Disabilities: People aged 65 or older or those with disabilities may qualify if specific income requirements are met.

Income Guidelines: Eligibility is determined by comparing your income to the Federal Poverty Level (FPL). Income limits vary based on differing situations and are subject to change at any time, so it is important to consult the latest guidelines to avoid future coverage issues.

Covered Services: Medicaid in Texas covers a range of services at little to no out-of-pocket cost, including:

• • Regular checkups and doctor visits

  • Hospital care

  • Laboratory tests and X-rays

  • Prescription medications

  • Vision and hearing care

  • Dental care for children

  • Mental health services

  • Long-term services and support for individuals with disabilities

Application Process: There are several ways you can apply for Medicaid in Texas:

• • Online: Create an account and complete an application at the Your Texas Benefits website.

  • Phone: Call 2-1-1 or 1-877-541-7905 to get real-time assistance with the application process with a live agent.

  • In Person: Visit a local HHSC benefits office to complete an application in person.

Renewal and Continuous Coverage: Continuous Medicaid coverage ended on March 31, 2023, due to legal changes. You must renew your benefits on time on the Your Texas Benefits website, over the phone, or in person in order to continue receiving coverage.

Q: What is prior authorization?

Prior authorization, also known as precertification or prior approval, is a process used by insurance companies to determine whether or not a prescribed product or service will be covered. Healthcare providers must receive approval from the patient's insurance company before delivering products or services to ensure they are covered, which can sometimes lead to delays in receiving treatment.

Q: Why do some medications require prior authorization from my insurance?

Insurance companies use prior authorization to ensure that a medication is medically necessary and meets their coverage criteria. This process helps manage costs and ensures that patients receive the most appropriate and cost-effective treatment options.

Q: What is a letter of medical necessity, and when is it needed?

A letter of medical necessity is a document written by your doctor explaining why you need a specific medication, including details about your medical condition and why alternative treatments may not be suitable. It is often required when seeking approval for prior authorization or an exception to your insurance plan’s formulary.

Q: When can I expect to know whether or not authorization was granted?

The time it takes to receive authorization ranges from a few days to a few weeks, depending on the urgency and complexity of the case. Standard medication requests usually require a few days with a possibility of expediting the process depending on the circumstances. Special medications and treatments usually require a few weeks.

Q: What do I do if the insurance company denies authorization?

Submit an appeal through your provider's office. An appeal is a formal request for your insurance company to reconsider its decision and review your case again. It usually includes any new or additional information given by your healthcare provider and an explanation as to why the prescribed treatment is necessary and the best course of action. You have up to 6 months (180 days) after receiving a denial to file an appeal.

Q: How does skin testing work, and is it painful?

Skin testing involves introducing small amounts of allergens into the skin and monitoring for reactions. It is generally done on the arm or the back using a plastic tip (it may cause mild discomfort but is generally not painful). 

To learn more, visit https://www.informedhealth.org/what-kinds-of-allergy-tests-are-there.html 

Q: What are allergy shots, and how do they help with allergies? 

Allergy shots are typically done on the arm by gradually introducing small doses of allergens subcutaneously to desensitize the immune system, reducing allergic reactions over time.

Q. What are some alternatives to allergy shots?

Sublingual immunology (SLIT) includes both allergy drops and allergy tablets, which are placed underneath the tongue as opposed to subcutaneously with traditional allergy shots. They are covered by most insurance plans and are approved by the FDA. SLIT work similarly to traditional allergy shots in that they contain small amounts of allergen and are introduced gradually over time as your body builds tolerance to the allergen. 

Q: What are the differences between biologics and IVIG therapy, and how do they help with asthma and allergies?

• Biologics are medications derived from living cells that help treat asthma and allergies by targeting specific immune system responses. They work by blocking proteins or immune signals that trigger inflammation and allergic reactions. (Ex: Dupixent, Xolair)

• IVIG (Intravenous Immunoglobulin) therapy provides additional antibodies (IgG) from healthy donors to help patients with immune deficiencies fight infections. (Ex: Cuvitru/Gammagard)

Q: How do I know if my insurance covers biologics like Xolair or Dupixent?

Check your insurance plan details or contact your provider to confirm coverage, as biologics often require prior authorization.

Q: How do I find out what my copay is?

There are multiple ways to find out what your copay is. The first way is to check if your insurance card lists the copay for doctor / primary care visits. If not, then you can log into your insurance company website or call your insurance provider to confirm your copay. Finally, you can also ask your doctor's office staff to verify your copay based on your plan.

Q: How can I find out if I’m eligible for a co-pay assistance program?

You can check your eligibility by visiting the drug manufacturer’s website or a dedicated co-pay assistance portal. Typically, you’ll need to enter your personal and insurance details, submit required documentation (such as proof of insurance), and review savings estimates. If approved, you’ll receive confirmation and instructions on how the savings will apply to your medication cost.

Q: How do I apply for a co-pay assistance program?

You can apply for a co-pay assistance program by following these steps:

1. Visit the Manufacturer’s Website – Go to the official website of the drug manufacturer or a dedicated co-pay assistance portal.

2. Check Eligibility – Review the eligibility criteria to ensure you qualify for assistance. Some programs may have income or insurance requirements.

3. Complete the Application – Fill out the online application form with your personal details, prescription information, and insurance details.

4. Submit Required Documents – You may need to upload or fax documents such as proof of insurance or a prescription from your doctor.

5. Receive Confirmation – Once submitted, you’ll get a confirmation email or letter with details on how the savings will be applied to your medication co-pay.

6. Use the Assistance – Follow the instructions provided to apply the savings at your pharmacy or through your healthcare provider.

Q: What is Buy-and-Bill?

Buy-and-bill is a process where healthcare providers, typically physicians’ offices, directly purchase medications (often biologics or specialty drugs) and then administer them to patients in the clinic. The office is responsible for managing the medication, submitting claims for reimbursement, and handling all the logistics involved.

Q: What is the difference in Buy-and-Bill for In-Office vs. At-Home Patients?

• In-Office Patients:

  • How it works: The medication is delivered to the physician’s office, where it's administered to the patient during their visit.

  • Benefits:

    • Control over the supply chain and drug integrity.

    • Easier insurance billing.

    • Close monitoring of the patient during treatment.

    • Potentially higher revenue and profit margins for the provider.

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• At-Home Patients:

  • How it works: The patient receives the medication via a pharmacy, often through mail, and administers it themselves at home.

  • Benefits:

    • More convenience, as patients can receive the treatment at home.

    • Personalization of care, with potentially more flexibility in administration (timing, environment).

    • Potentially less frequent in-office visits.