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Health Insurance and Asthma
General
information about health insurance and asthma:
- If
you have a Medicaid health plan, those covered services and
benefits
are mandated by law, and by policy actions from the
state.
- Generally,
people have group coverage that is negotiated between the
employer and the insurance carrier – not all group plans are
the same. This coverage may change at the time of renewal due
to these negotiated changes.
- Because
of this give and take between employer and insurance carrier,
you may want to tell your employer about your specific needs. For example, if asthma education is not now a covered
benefit, you could ask your employer to have that benefit
added to the coverage on the next contract. Remember, though,
that a plan is not likely to add a benefit to the package
because only one member needs it.
- If
the inhaler you are prescribed needs a specific spacer, or if
a spacer comes with the inhaler, it may be covered under your
pharmacy benefit, even if valved-holding chambers or spacers
are usually covered under your DME (durable medical equipment)
benefit. Check
your benefit guide or call your insurance plan if you are
unsure under which benefit your spacer is covered.
- If
you are told that a medication that has been prescribed for
you is not on your insurance company’s formulary (a
formulary is the list of drugs that your insurance carrier
covers), you can talk to your doctor about alternative
medications, or the doctor may arrange for insurance coverage
of the medication.
Questions
you may want or need to ask your insurance provider:
- “Are
asthma education classes a covered benefit for my child or
me?”
- “How
can I get a referral to a doctor who specializes in asthma?”
- “Where
can I get a peak flow meter? Is it covered under my pharmacy
or DME benefit?”
- “If
a valved-holding chamber or spacer isn’t covered under my
pharmacy benefit, is it covered under the DME benefit?”
- “How
often am I able to get my prescriptions filled?” (Some plans have limits on the frequency of refilling)
Tips
for getting better service from your health plan…
- Work
with your doctor or asthma counselor to find out all you can
about basic asthma facts, your own asthma, and what it will
take to keep it under control.
Many health plans have websites and customer service
numbers that you can call to ask for free brochures, classes
and other information about community services to help you.
- Call
your plan’s customer service department and ask specific
questions.
- Find
out if your plan has case managers – if it does, you can ask
to speak with a case manager about your problem. They can be
very helpful!
- Mistakes
do happen, and sometimes a health plan may “deny” coverage
for a covered benefit.
If
you think this has happened to you, call your health plan. They
should work with you to take care of the problem. If you are still
not satisfied, you can appeal to the health plan by following
their complaint/grievance procedures.
If
you are unable to fix the problem working with the health plan on
your own, the new Michigan Patient Bill of Rights guarantees you
these rights:
- information
about your insurance plan
- health
coverage sooner for problems that existed before you
enrolled in your health plan
- faster
and clearer ways of handling complaints
These
rights are guaranteed if you have health coverage through:
- Blue Cross and Blue Shield of Michigan
- a
preferred provider organization (PPO)
- a
health maintenance organization (HMO)
- a
state-regulated health insurance company
This new law does not
apply if your health coverage is through a private self-insured
employer, and you enroll in an option that is not covered by state
rules. Federal law applies in those situations. If you need more information about your
rights, call the Michigan Insurance Bureau at (517) 373-0240.
Click
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Material on this page was compiled from tips by
members of the Quality Improvement Work Group (part of the Asthma
Initiative of Michigan) who have experience handling insurance and
asthma problems.
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