IBD Insurance Checklist
How This Checklist Can Help You
The IBD Insurance Checklist is designed to help you compare insurance plans and consider your health needs when shopping for insurance in the Health Insurance Marketplace/Exchange. You may also consider using this checklist for insurance plans outside of the Marketplace, as it is a helpful guide for any IBD patient comparing insurance plans.
When thinking about your choices for health coverage through the Marketplace, there are many additional choices to consider besides the plans’ monthly premium. This checklist is a useful guide to help you find a plan that will meet your healthcare needs. Keep in mind, you may not need all the treatments or services in the checklist, and there may be other treatments, costs, or aspects of your care that you need to consider.
Fill in the following worksheets for each insurance plan you are considering. By doing so, you will be able to tell which insurance plan best fits your needs and your budget.
For more information on paying for health insurance or receiving assistance from a healthcare navigator in choosing and applying for a Marketplace plan, visit www.healthcare.gov or call 1-800-318-2596 / TTY: 1-855-889-4325
Additionally, The National Health Council has an extremely helpful website where you can get detailed information about out-of-pocket costs for health insurance and medical expenses within the
When To Use This Checklist:
If you or a family member have Inflammatory Bowel Disease
(IBD)
When evaluating insurance plans and options
When discussing your insurance needs with a Marketplace
healthcare navigator
When discussing your needs as an IBD patient with your
healthcare provider
marketplace as a chronic disease patient. The site also has a feature to estimate your costs for health insurance, including medication specific costs:
http://www.puttingpatientsfirst.net/
This fact sheet was adapted from www.CancerInsuranceChecklist.org
MY CURRENT CARE
List your current healthcare providers and health services. After doing so, review the insurance plan you are considering to see if your current providers, medications, hospital, etc., are covered in the plan, and if they are considered in-network or out-of-network. Using providers that are in-network will be more cost efficient. Out-of-network providers will likely result in higher out-of-pocket costs.
Type of Provider/Service
Name of Provider/Notes In-Network Out-of- Network My Primary Care Doctor: My Specialist Services: (i.e. Gastroenterologist, Infusion Center, Psychologist, etc.) My Hospital: My Diagnostic/Lab Tests:
(i.e. routine blood work, colonoscopy, MRI, etc.) My Medications: (Including all prescriptions, over the counter medications, and/or any medication given at infusion center) My Additional Health Services:
(i.e. Infusion center, home health aide, etc.)
MY TREATMENT AND HEALTH CARE NEEDS
Complete this chart for each insurance plan you are considering. By completing this chart, which considers services you may need as a patient, and reviewing the services covered by the
Marketplace insurance plan(s), it should help you find the plan which best fits your needs.
Type of Service Covered? Do I need a referral or pre-authorization?
What is the co-pay/coinsurance/
deductible?
What are the limits or maximums?
Primary care visits Y / N Y/ N
Specialist visits Y / N Y / N Emergency room Y / N Y / N Urgent care Y / N Y / N Hospital care Y / N Y / N Prescription medications Y / N Y / N Preventative
Screenings (i.e. colon cancer screening, skin cancer screening)
Y / N Y / N
Imaging/diagnostic testing (i.e. colonoscopy, CT Scan, complete blood count, vitamin panel)
Y / N Y / N
Surgery
(continued on next page)
Type of Service Covered? Do I need a referral or pre-authorization?
What is the co-pay/coinsurance/
deductible?
What are the limits or maximums?
Infusion/injection Therapy
(i.e. Remicade, Humira, Cimzia)
Y / N Y / N
Infusion center
(i.e. Where you go for Remicade treatments)
Y / N Y / N
Second opinion Y / N Y / N
Clinical trials Y / N Y / N
Mental health services Y / N Y / N
Pain management Y / N Y / N Physical therapy Y / N Y / N Home healthcare Y / N Y / N Ostomy/medical supplies Y / N Y / N Additional Blood Testing Doctor May
Recommend:
(not always needed)
Covered? Do I need a
referral or pre-authorization?
What is the co-pay/coinsurance/
deductible?
What are the limits or maximums?
Biomarker blood testing(Testing for markers of Crohn’s disease or
ulcerative colitis)
Y / N Y / N
Thiopurine testing/ monitoring
(Allows a patient to start medication with confidence, and monitors ongoing medication levels for safety)
Y / N Y / N
Biologic response testing
(Learn what is contributing to loss of response to a biologic therapy)
MY COSTS TO CONSIDER
Fill in the boxes on the right for each insurance plan you are considering.
Plan name:
Type of plan: Platinum Gold Silver Bronze Catastrophic
# of people in my household:
Total household income per year: $
How much is the premium? Per month: $ Per year: $
How much is the deductible? Per year: $
How much are the co-pays? Primary care visits: $ Specialist visits: $ Hospital: $ ER: $ Urgent Care: $ Prescription Drugs: $ Other: $
How much is the coinsurance? $ or %:
What is the maximum out-of-pocket expense?
Per individual per year: $ Per family per year: $
Do I qualify for a reduction in maximum out-of-pocket costs? (silver plans only)
Can I get a tax credit for the premium?
Amount per year: $
GLOSSARY OF TERMS
Term Definition
COINSURANCE Your share of the costs of certain medical care or medications, calculated as a
percentage of the total cost. For example, if the health insurance plan’s allowed amount for an office visit is $100 and you’ve met your deductible, your coinsurance payment of 20% would be $20. The health plan pays the rest of the cost.
COPAYMENT A fixed amount (for example, $15) you pay for certain medical care or medications. The amount can vary by the type of health care service.
DEDUCTIBLE The amount you pay for health care services before your health insurance plan begins to pay. For example, if your deductible is $1,000, your plan won’t pay anything until you’ve spent $1,000 on medical care or medications. However, some services, including preventive services, may not be subject to the deductible. Be sure to check your plan.
FORMULARY TIER The level of cost-sharing assigned to a particular medication or therapy. Services assigned to a higher tier typically cost more than those assigned to a lower tier.
IN-NETWORK The term used to describe when a provider is included in a plan’s network. In-network
providers can also be referred to as preferred providers.
GENERIC MEDICATION
A prescription drug that has the same active-ingredient formula as a brand-name drug. Generic drugs usually cost less than brand-name drugs. The Food and Drug
Administration (FDA) rates these drugs to be as safe and effective as brand-name drugs.
METAL LEVEL Plans are categorized by “metal levels”—Bronze, Silver, Gold, and Platinum. Metal
levels tell you what portion of total health care costs plans will cover. For example, Bronze plans typically pay around 60% of a person’s health care costs, and Platinum plans cover closer to 90%.
OUT-OF-POCKET COSTS
The costs you pay that are not covered by insurance when you visit a doctor, hospital, or pharmacy. Examples of out-of-pocket costs include copayments, coinsurance, and deductibles.
OUT-OF-POCKET MAXIMUM
The most you pay before your health plan begins to pay 100% of the cost for in-network services. This limit never includes your premium or health care your plan doesn’t cover. Health plans count all in-network copayments, deductibles, and coinsurance payments to this limit. The maximum out-of-pocket limit for any marketplace plan in 2014 cannot be higher than $6,350 for an individual plan and $12,700 for a family plan.
PLAN FORMULARY The list of medications that your health plan covers. Sometimes called a “List of
Covered Drugs.”
PLAN NETWORK The facilities, health care providers, and suppliers your health plan has contracted with to provide health care services.
PREAUTHORIZATION A term used by health plans to convey that before seeking certain health care services, patients must seek prior approval or permission. Services such as home health care and non-urgent surgeries often require preauthorization.
PREMIUM The amount you pay every month for your health insurance plan.
Courtesy of the National Health Council www.puttingpatientsfirst.net
