Health Insurance Crash Course

If you have private health insurance coverage, do the words “lifetime maximum benefit” strike fear into your heart? Do you worry about “maxing out” your health insurance benefits? If so, then this article is for you.

As a quick definition, a lifetime maximum benefit is a cap on the total amount of benefits available to you as a member of your health plan. In other words, it’s the most money your insurance company will pay for your medical expenses over your lifetime while you are under the plan.

Most lifetime benefit maximums are capped at up to $1 million or $2 million. While this may seem like a lot of money, you can go through it fast when you consider the health costs associated with managing a chronic medical condition, such as a bleeding disorder.

Fortunately, more and more insurance companies are opting not to include a lifetime maximum benefit in their plans. However, if your health plan does have a lifetime maximum benefit, it’s crucial for you to know how to manage it so you don’t “max out” your health insurance benefits.

Keeping Track of Your Lifetime Maximum Benefit
The simplest way of managing your benefits is to keep track of how much your insurance company is applying to your plan’s lifetime maximum. You can do this a few ways. First, federal law requires that certain health plans, such as Preferred Provider Organization (PPO) plans and Point of Service (POS) plans, provide its members with an Explanation of Benefit form (EOB) whenever you submit a claim. The EOBs you receive should include the amount remaining in your lifetime maximum benefit. If your health insurance company does not provide you with EOBs, then you should contact them to check your lifetime maximum benefit every six months, or after you or someone in your family experiences a major medical treatment or hospitalization.

Once you have exhausted half of your plan’s lifetime maximum, you should begin to plan to switch coverage. For example, let’s say under your current plan you have a lifetime maximum benefit of $1 million. You check your records and find that you have $500,000 left. This is the point where you should start looking into switching health plans.

While the idea of switching health plans may seem overwhelming at first, fortunately there are many more options for alternative coverage today than in the past. And, by looking into alternative plans early, you allow the time to explore all your options and to choose the best possible plan for your situation. Also, there may be a waiting period before you can participate in your new plan. So having money left in your lifetime benefit will help you avoid maxing out your coverage before you can make the switch.

When It’s Time to Switch Plans
When thinking about switching health plans, first explore the options available through your current employer. Many employers offer several types of plans (for example, an HMO and a PPO). So, if you have used up half of your lifetime benefit under your employer’s HMO plan, you will start with a new lifetime benefit (e.g., $1 million or $2 million) if you switch to their PPO plan.

Remember, when switching plans in your company, you will need to wait until open enrollment, the annual period when employees may make changes to their healthcare benefit plan options. This is another reason to start looking into switching plans when you still have half of your lifetime maximum benefit left. By carefully keeping track of your benefits, you can help ensure that enough of your lifetime benefit is left until you are able to switch during open enrollment.

Of course, when switching health plans, always carefully review the plan you are considering to ensure that it will best meet your needs. For example, you should check to see what the lifetime maximum benefit is and whether or not the new plan will cover factor replacement therapy. For a detailed list of things to consider when switching health plans, check out the health insurance checklist in the pocket of this newsletter.

If your employer only offers one plan, and you are reaching the halfway mark in your lifetime maximum benefit, you may want to think about switching jobs or obtaining health insurance through your spouse’s employer. If your spouse doesn’t work, he or she may want to consider finding employment—even part-time employment. Many companies now offer comprehensive health benefits to part-time employees, but there may be a longer waiting period to join the plan. For a list of companies that offer health insurance benefits to part-time employees, contact A.C.C.E.S.S., which stands for Advocating for Chronic Conditions, Entitlements, and Social Services, at 1-888-700-7010. A.C.C.E.S.S. is a program dedicated to helping find solutions to the social and economic problems that confront families living with chronic conditions.

While these may sound like drastic steps, going without health insurance when you or someone in your family has a chronic disorder can be financially devastating. It’s important to do everything you can to maintain health insurance.

If switching jobs or going under a spouse’s health insurance plan are not options, you may be able to access group health insurance other ways, such as through a professional organization. You can also purchase private health insurance, but this often is more costly and not as comprehensive as group health insurance. Also, you or your family members may be eligible for certain government-sponsored health insurance programs. One such program is KidsCare, which provides comprehensive health insurance to children 19 years old or younger for families who qualify. There are also state-run programs specifically designed for people with chronic disorders. Check with your local Hemophilia Treatment Center, Chapter, or homecare company for options.

You also can contact CSL Behring Reimbursement Services, which is staffed with highly trained representatives experienced in health insurance issues. You can reach CSL Behring Reimbursement Services toll-free at 1-800-676-4266.