Insurance: choosing a health plan

Most people will have several different health plans over their lifetime. Choosing a health plan can be one of the most important decisions you and your family make.

If you find yourself reviewing a number of different plan options, here are some important factors to consider:

• Is your current physician/dermatologist/rheumatologist included in the new plan's list of doctors?
• Is your current treatment covered by the plan? Keep in mind, psoriasis treatments generally will not be discussed in the summary sheets that your employer provides you about your health plan. You will need to contact the health plan directly, or have your employer do so, to find out if your specific medications are covered and what type of coverage to expect.
• Will you be responsible for a co-payment?
• Is there a maximum annual prescription benefit? Some health insurance plans may cover treatments like biologics, but have an annual prescription benefit "cap" or maximum amount that is paid for these medicines. For example, Plan X may cover a certain medication, but will only pay $3,000 in annual prescription costs. Once this cap is reached, you are responsible for any additional costs over $3,000.
• Are you expected to pay a deductible before your health insurance will begin covering your medicines?

If your health care coverage is through your employer and you have questions or concerns, meet with a representative from the department in your company that negotiated the new health plan, typically the human resources (HR) department.

If you are choosing your own health insurance, contact a representative from the health plan to discuss your specific health care needs.

In either situation, you should be prepared to tell the person you speak with about your psoriasis and/or psoriatic arthritis. The National Psoriasis Foundation can provide you with resources to help you educate others about psoriatic diseases.

Different types of health plans

There are many different kinds of health plans and many variations of each type. Included below are basic descriptions of some of the most common plans.

Indemnity plans

Indemnity plan subscribers are allowed to visit the provider of their choice. Typically, subscribers must pay an annual deductible before the insurer will cover any bills. Beyond the deductible, any additional costs are split between the insurer and the patient according to the ratio your employer has negotiated. (e.g., Patient pays 20 percent, insurer pays 80 percent).

Preferred Provider Organization (PPO)

Subscribers to a PPO can visit doctors within or outside of an approved network, with a co-payment for each visit. The insurer usually pays a percentage of any medical fees. If you choose to visit a provider who is outside your network, you may need to pay a deductible and your overall share of the cost of the service is often higher than for in-network services.

Health Maintenance Organization (HMO)

HMO subscribers pay a monthly fee for their benefits. Subscribers choose a primary care provider (PCP), whose referral is required for a visit to a specialist such as a dermatologist or rheumatologist. Without a referral, you may have to pay all of the charges, so be sure to read your plan carefully. Likewise, if you choose to visit a doctor who is not part of the HMO, you will be responsible for some or all of the charges.

Point-of-Service Plan (POS)

A POS is like a combination of an HMO and a PPO. Like an HMO, subscribers to a POS have a primary care provider. Like a PPO, subscribers can visit doctors who are both in- and out-of-network. If you choose to visit an out-of-network provider, you may be required to file additional paperwork with the insurance company. Subscribers can choose their own specialist or be referred by their primary care provider. If you refer yourself without getting clearance from your PCP, you will be responsible for a larger portion of the costs.

Medicare

Medicare is for Americans age 65 and older and people with certain disabilities. For additional information, visit our Medicare and Medicaid page.

Medicaid

Medicaid is for people with disabilities and some low-income individuals. For additional information, visit our Medicare and Medicaid page. Medicaid is run differently in each state, so contact your state office to learn about its program.