Advocating for yourself
Choosing an insurance plan

Choosing an insurance company can be one of the most important decisions you and your family will make. Most people will have several different insurance plans over the course of their lifetime. Individuals often change insurance plans when they change jobs or relocate. Even if you do not change positions, your healthcare plan may still change. Employers often renegotiate their insurance plans over time to obtain better coverage for their employees or to save money. If you are self-employed or work for a small company, you may need to purchase your own health insurance. Many of the tips discussed in this section will also be useful when purchasing your own health plan.

Some employers offer several different options to employees when it comes to insurance. If possible, talk to your employer about your psoriasis/psoriatic arthritis and the type of coverage you can get through your insurer. Keep in mind, you may have little choice in the plan your employer chooses. This makes it even more important to let your employer know about your condition.

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

1. Is your current physician/dermatologist/rheumatologist covered under the new plan?

2. Is your current treatment covered by the plan? Keep in mind, psoriasis treatments generally will not be discussed in the summary sheets your employer provides you about your health plan. You will need to contact the insurance company, or have your employer do so, to find out whether or not your specific medications are covered and what type of coverage to expect.

3. Will you be responsible for a co-payment?

4. Is there a maximum annual prescription benefit? Some health insurance plans may cover expensive treatments like biologics, but may have an annual prescription benefit cap. For example, Plan A may cover a certain medication, but will only cover $3,000 in annual prescription costs. Any costs over $3,000 are the responsibility of the patient.

5. Are you expected to pay a deductible before your health insurance will begin covering costs?

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

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

In either case, you should be prepared to educate the person about your condition as s/he may know little about psoriasis or psoriatic arthritis. The National Psoriasis Foundation can provide you with resources on both conditions to help your conversation.

Different types of health insurance

Indemnity plans

Indemnity plans are a more traditional type of health insurance. Subscribers to this type of plan are allowed to visit the physician of their choice. Typically, subscribers will be responsible for an annual deductible, which they will be charged before the insurer will cover any bills. Once the deductible is paid, any additional costs are split between the insurer and the patient according to the ratio you or employer has negotiated. For example, you may be responsible for 20 percent of your healthcare costs and your insurer will pay the remaining 80 percent of charges.

Preferred Provider Organization (PPO)

Subscribers to a PPO have the option of visiting doctors who are both in and out-of-network. Typically, it is less expensive to use in-network physicians and hospitals because the insurance company has arranged an agreement with them. You will need to pay a co-payment each time you visit your doctor's office. The insurer usually pays a percentage of any medical fees. If you choose to visit a physician who is outside your network, you may need to pay a deductible and the overall percentage of the cost of the services you must pay for is often higher than for services provided in-network.

Health Maintenance Organization (HMO)

Subscribers to an HMO pay a monthly fee for their benefits. In exchange, they receive health benefits, including preventative care. Subscribers to an HMO choose a primary care physician. Typically, you will need a referral from your primary care physician before visiting a specialist, such as a dermatologist or rheumatologist. If you visit a specialist without getting a referral, you may be required to pay for all of the charges, so be sure to read your plan carefully. Additionally, if you choose to visit a doctor who is not part of the HMO, you will be responsible for all or some of any charges.

Point-of-Service Plan (POS)

A POS offers coverage similar to a combination of an HMO and a PPO. Like the coverage offered by an HMO, subscribers to a POS have a primary care physician. Like a PPO, subscribers can visit doctors who are both in and out-of-network. In a POS, subscribers can choose their own specialist or be referred by their primary physician to a specialist. If you choose to visit an out-of-network provider, you may be required to file additional paperwork with the insurance company. If you refer yourself to a provider without getting clearance from your primary care physician, you will be responsible for a larger portion of the costs than if you would be had you been referred by your doctor.

Medicare

Medicare is for Americans age 65 and older and people with certain disabilities. For additional information, please review the information here.

Medicaid

Medicaid is for people with disabilities and some low-income individuals. For additional information, please review the information here. Medicaid is run differently in each state, so you will need to contact your state office to learn more.

Steps to take once you are insured

Any time you contact your insurance company, record the time and date of your call and the name and job title of the person with whom you spoke. You should also keep a record of any contact with your doctor and conversations you have with your employer about your insurance. Please also review working with your doctor and tips for being your own best advocate.

1. Review the details of your plan carefully. Many insurance companies require you to contact them before visiting certain doctors or obtaining certain kinds of treatment. If you do not contact your insurance company first or get referred properly by your primary physician to a specialist, such as a dermatologist, your health plan may refuse to cover the charges outright, or may cover less of the charges than they would have if you had notified them in advance.

2. Obtain copies of the medical policies relevant to your current treatment and any treatments you and your doctor are considering. You will not typically find information on psoriasis and psoriatic arthritis treatments in the materials provided to you by your employer. You need to contact the insurance company directly or find the policies online.

   Once you obtain copies of any policies relevant to psoriasis or psoriatic arthritis treatments, please share them with the National Psoriasis Foundation. The advocacy department of the Psoriasis Foundation keeps a record of this type of data, and when necessary, uses this information to target insurance companies whose policies on psoriasis and psoriatic arthritis treatments are out of alignment with the current standard of care. Taking a few minutes to share this information with us will help others in the psoriasis community in the future. To share a copy of your insurance company's policy with the Psoriasis Foundation, e-mail advocacy@psoriasis.org or fax a copy to 503.245.0626, Attn. advocacy department.

3. If you have additional questions, contact a representative at your insurance company. Keep in mind, most insurance representatives will be unfamiliar with your condition. Remember to be patient. Educate them about psoriasis and psoriatic arthritis as you ask questions to get the best answers.