Understanding your insurance options

Health insurance comes in many forms:

• Group-sponsored Health Insurance: Offered through employers or spouse/domestic partner's employer.
• Private Coverage: Directly purchased from insurance carriers.
• Exchange Plans: Purchased through state or federal exchanges, with possible subsidies based on income.
• Medicare: A federal program for individuals aged 65 and older.
• Medicaid and Children’s Health Insurance Program (CHIP): Available for qualifying individuals with disabilities or conditions.

Health insurance plans can be classified into 4 primary categories, each with its own set of features:

1. Health Maintenance Organization (HMO): Limited to in-network providers, requires a primary care physician (PCP), and referrals for specialists.
2. Exclusive Provider Organization (EPO): Restricts care to in-network providers but doesn't require a PCP or referrals.
3. Point of Service (POS): Allows both in-network and out-of-network care, but PCP and referrals are needed.
4. Preferred Provider Organization (PPO): Provides in-network and out-of-network coverage without requiring a PCP or referrals.

With a fully insured plan, the employer pays a fixed monthly premium to an insurance company, covering plan administration and claims. The insurance company bears the loss if claims exceed expectations.

With a self-funded plan, the employer pays a monthly fee to an insurance company for administration and claims adjudication but covers the actual claims costs. The employer benefits if costs stay below expectations and has more flexibility in plan features.

Health insurance companies use various strategies to manage specialty medication costs, including prior authorizations and step therapy. Stay informed about new trends, such as co-pay accumulators, and explore financial assistance programs.

Watch the New Rx Trends chapter in the video below for more details.

To understand your coverage, review the Summary of Benefits and Coverage (SBC) provided by the insurance company. It outlines co-pays, deductibles, and out-of-pocket maximums.

For detailed coverage information, you can get the medical policy from the insurance company's website or call their Member Services department.

During open enrollment, consider the following factors to make the best decisions for your family's healthcare needs:

• Estimate your annual expenses, including co-pays, coinsurance, deductibles, and out-of-pocket maximums.
• Compare total costs of different plans, including in-network and out-of-network expenses.
• Check if your prescriptions, especially growth hormone medications, are covered similarly in each plan.
• Attend open enrollment events, ask questions, and seek assistance to understand any changes to the plan.

Be proactive in the prior authorization and appeals process by documenting all communications between you and your insurance company.

If you face a denial, involve your child's doctor, focus on medical necessity, and provide evidence to support your appeal. Always advocate for yourself and your family to get the medicine you need!

Various advocacy organizations offer support and educational resources. Seek assistance and advocacy to ensure you have access to the best healthcare options.

Click here to explore some of these organizations and more GHD resources.