Meds, Mind, Body & Benefits > Insurance, Benefits Programs & HIV

Health Care Reform: What It Means for PLWHIV

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hereinny:
Can anyone tell me about prescription coverage?
I have GHI with no prescription coverage, my union provides me with a plan through express scripts that gives me 7500 per year in prescriptions.  From there my union has me enrolled in a group catastrophic plan that pics up once the other insurances run out up to 2million dollars.  Right now my meds are 18000 per year.  My catastrophic picks up 11,500 of that.  Im afraid i am going to lose the group plan with this new legislation and have to pay that myself.  I called my union and nobody can tell me an answer to what is going to happen because there are so many unanswered issues in this bill.
Anyone have any insight?

Assurbanipal:

--- Quote from: skeebo1969 on March 27, 2010, 10:41:56 AM ---Thanks Tim, if I am understanding this correctly annual limits will be eliminated by 2014. 

 Edited to add:  I've reviewed it further and it looks like our annual limit would remain effective even after 2014.  From what I gather, it seems to state the limit cannot exceed $2000 annually per individual, $4000 family.  Our limit right now is $2500, which we usually meet around the end of the fiscal year, just in time for it to reset. 

 So I don't stray this topic on my own individual needs if I am missing something, please provide me any info to the contrary via PM. Indeed, I do hope I am wrong about this.

--- End quote ---

By "annual limit" health care reform refers to the maximum amount that the plan will pay in benefits per year.  Most plans today have a lifetime limit of between $1 and $5 million in benefits.  This is no longer allowed under the new law effective within the 2010 year.  Also for 2010 plans can only have annual limits on what they will pay per year that are "reasonable"  Kathleen Sebelius, the Secretary of Health and Human Services ,will issue regulations that say what is a "reasonable" annual limit is.

It sounds like you are more interested in the limits on what you will pay.

If you get your health care coverage from an employer plan, what you pay comes in four forms:
- some plans charge you a monthly premium
- most plans only start to pay benefits once you have already paid some amount without any help from them -- the amount you pay before the plan pays anything is called your deductible  The $2,000 and $4,000 amounts you refer to above are the new maximum deductible amounts starting in 2014 for group insurance plans sold to small employers
- many plans require you to still pay a fraction of health care costs when they start to pay benefits at all -- these payments are your co-insurance amount
-- or they may require you to make a flat payment (e.g. $10) each time you get care -- these payments are called co-pays
- many plans today, and the new insurance plans that are sold on the exchanges in 2014, have a maximum limit on what you are required to pay in a year -- this is the maximum out of pocket limit. Once your deductibles, co-pays and co-insurance reach the mamximum out of pocket limit the plan pays everything until you reach the annual or lifetime limit on plan payments.

So the maximum on how much you will pay in the future will be whatever you pay in premiums plus your out of pocket maximum. 

skeebo1969:


   You are right Mr. Urban, it is the deductible I was referring to.   Are the annual deductibles going to be eliminated? Right now our monthly premiums are $596 monthly.  The co pays are all fine and understandable, but it is the deductible portion of our plan that really is killing us.  When I see my doctor at the beginning of the year I pay $150 out of pocket, and of course this does not include any of the lab costs and such.  There are 3 on the policy, of which 2 of us require constant medical attention... this is what is giving my wife and I fits.  My little one recently had pneumonia and the X-ray alone cost me over $300 out of pocket...  once again because we had yet to meet the deductible set forth by our plan.  By the time we reach the $4000, of which co pays don't go against, it's already time for it to reset.

   It's gotten to the point where the only thing I let my doctor check are my Cd4's and Vl, it's just that bad. :(

Tim Horn:
I think Assurbanipal explained the basics of health insurance coverage beautifully.

Fact is, many insurance companies will continue business as usual -- some offer plans with higher premiums but with lower co-insurance and co-payment amounts; others offer plans with lower premiums with high co-insurance and co-payment amounts.

What's really important here is not only are people living with HIV basically guaranteed health insurance, they will have the option of choosing the best policy to suit their needs (and the needs of their families, if dependents are involved). For example, if you're working for a company offering an insurance plan that simply doesn't meet your needs, and your income is within 400 percent of the federal poverty line (e.g., a household of two making less than $58,280), employers are required to provide a free voucher (the payout must be the same as the policy offered by them) that can be used to buy insurance in the state-run Exchanges that will be set up.

Tim

    

Assurbanipal:

--- Quote from: hereinny on March 27, 2010, 10:42:12 AM ---Can anyone tell me about prescription coverage?
I have GHI with no prescription coverage, my union provides me with a plan through express scripts that gives me 7500 per year in prescriptions.  From there my union has me enrolled in a group catastrophic plan that pics up once the other insurances run out up to 2million dollars.  Right now my meds are 18000 per year.  My catastrophic picks up 11,500 of that.  Im afraid i am going to lose the group plan with this new legislation and have to pay that myself.  I called my union and nobody can tell me an answer to what is going to happen because there are so many unanswered issues in this bill.
Anyone have any insight?

--- End quote ---

It sounds like the union is the official plan sponsor of your catastrophic plan?  If so, they will have to remove the $2million limit on what the plan pays but not be forced to do much else before 2014.

One of the problems for the union, though, is that the catastrophic plan is currently written to pick up and provide you with benefits where the Express Scripts plan leaves off, when the Express Scripts plan hits its annual limit of $7500.

There will be new rules, coming out soon, that might make Express Scripts change the $7500 annual limit, if it is not "reasonable".  But there's not much info or even informed speculation on what a reasonable limit will be yet.  But it goes into effect quickly.

So at this point, the union is waiting to find out what Express Scripts is going to do and then figure out what they can afford to do in response.  Express Scripts is waiting to find out what a reasonable annual limit will be...





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