Selecting the right insurance policy is critical for individuals with cystic fibrosis. Many issues must be evaluated and many concerns must be addressed before selecting an appropriate policy.
The following Policy Checklist has been compiled to use as a guide for reviewing existing coverage and evaluating potential coverage when selecting an insurance policy.
Access to Care
Will the plan cover the full range of specialized care for you and provide access to cystic fibrosis accredited care centers?
Will you have your own physician? Can you see him/her at each visit? Is it possible to obtain approval for unlimited access to a board certified pulmonologist and/or gastroenterologist?
Does the plan use primary care providers, who are not physicians, such as nurse practitioners, registered nurses, and physicians' assistants to give routine care?
What can you do if you don't like your care, or if your primary care physician refuses to send you to your chosen specialist when you think you need it?
Are home nursing and physical therapy visits covered? Is this coverage limited in any way?
What services require prior approval (pre-certification) from the company?
Benefits & Limitations
Does the plan cover medications? If yes, to what extent, and are there limitations governing the coverage of specific drugs and drug treatments, including Pulmozyme®, TOBI ®, and infusion therapy?
Does the policy have a "pre-existing condition"? If so, for what length of time?
What medical conditions are explicitly not covered? Are there riders or coverage waivers?
Is there a maximum lifetime benefit or a dollar limit on care?
What happens if you need care when you are out-of-state or out of the plan's area of coverage?
Is there a penalty if you go outside the network?
Claims
How are claims filed? Who files them?
How are claims paid or reimbursed? Do you have to pay up-front or will the payor pay the provider directly?
What is the procedure for filing a complaint or appealing a decision with which you disagree?
Does this policy coordinate benefits with other policies under which you or family members may be covered?
Costs
Is there a deductible? If so, how much is it? How often do you have to pay the deductible?
Is there a co-payment for physician office visits, prescriptions, or hospital services? If so, how much? What is the limit on your out-of-pocket expenses?
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