Your Coverage & Care
Your Coverage & Care
 
Choosing the Right Coverage
  • Arthritis Care Checklist

    If you’re newly insured, thinking about switching plans, or considering supplemental coverage, there are 10 key areas of health care services that people with arthritis may need. You should ask yourself, your provider and/or your insurer some important questions before getting care. This will help you to get the most from your coverage and minimize or eliminate claim denials.

    Explore this section to learn more about questions to ask for:

    • Primary care
    • Emergency care
    • Specialty care
    • Medications
    • Dental and vision care
    • Imaging and laboratory tests
    • Non-physician specialist care and complementary therapies
    • Mental health
    • Surgery
    • Medical devices, mobility aids and orthotics 
  • Primary Care

    You’ll need your annual physical and ongoing care for general health needs (e.g., allergies, respiratory infections, ear aches, stomach aches, breast health checks, weight management, etc.). It’s a good idea to have one doctor who tracks your health on an ongoing basis. Here are a few questions to ask:

    • Does the insurance plan require me to choose a PCP?
    • Can I use out-of-network providers? How much more will I pay?
    • Do copays change depending on how many sick care visits I use in a plan year?
    • Are primary care services subject to the deductible?
    • Are preventative health services subject to the deductible?
    • Will the PCP coordinate my arthritis care with specialists?
    • Will the insurance plan compensate the PCP for those services?
    • Do I need a PCP referral to see a specialist before I can make an appointment?
    • What are my options if the PCP disagrees that I need to see a specialist?
  • Emergency Care

    Here are a few questions to ask about emergency coverage:

    • What is the copay or coinsurance for using emergency services?
    • Is an urgent care clinic a cost-effective alternative?
    • Can I utilize a nearby walk-in facility if it’s not in network?
    • If I use an out-of-network provider, are the services subject to the deductible?
    • In my state, can an out-of-network emergency provider “balance bill” me if the provider’s rates are higher than the plan allows? 
  • Specialty Care

    Depending on the type of arthritis you have, you may need access to different specialists. Make sure the health plan allows you access the following:

    • Rheumatologist
    • Pain specialist
    • Cardiologist
    • Physiatrist
    • Immunologist
    • Orthopedist
    • Neurologist
    • Psychiatrist
    • Podiatrist
    • Sleep clinic provider

    Here are a few questions to ask:

    • Do I need a referral from my PCP before seeing a specialist?
    • Is the provider in the plan’s network? Do I need a pre-authorization to get care?
    • What’s the copay or coinsurance?
    • If the provider is out of network, can I request estimated charges before service is provided?
    • What are my options if there is a long wait time to see an in-network specialist?
    • If the provider is out-of-network, must I pay at the time of service or can I wait until the provider sends me a balance bill (if necessary)?
    • Is there a limit to the number of visits for each type of specialist in a plan year?
    • Is the lab, imaging center or infusion center that the specialist uses included in my plan’s network?
    • What are the additional costs if the lab or center is out-of-network?
      • Is preauthorization required?
      • Will I need to pay in full and submit a claim for reimbursement? 
  • Medications

    Managing your condition may require over-the-counter and prescription drugs in the form of pills, topicals, injections or infusions. Injections or infusions may be given in a doctor’s office or infusion center. Here are a few questions to ask before filling a prescription or receiving an injection or infusion:

    • Which tiers on the formulary are my drugs on?
    • Do I need pre-authorization to fill a prescription?
    • Do I need to use a specific pharmacy?
    • What’s my copay or coinsurance?
    • Will it be cheaper if I use mail order?
    • Are there certain drugs that are mandatory mail order?
    • Is there a limit to the number of pills I can get in a single refill or the number of refills in a plan year?
    • Do I need to use a specific infusion center?
    • Is there a limit to the number of injections or infusions I can get in a plan year?
    • Is there a medication deductible that is different from my major medical plan deductible?
    • Is there an annual out-of-pocket maximum?
    • Is there an annual or lifetime cap for what the plan will cover?
    • Does the plan require mandatory use of generic if available?
    • If a drug I took while covered by another insurer didn’t work, do I have to fail on that drug again with the new insurer before requesting an alternative (step therapy)
    • Are auto-injectors covered or do I have to use refillable syringes?
    • Do I have to pay a medical copay and prescription copay to get injections at a doctor’s office?
    • Are there special considerations for infused medications?
    • If my medication is not on the formulary, can I request an exception?
  • Dental and Vision Care

    Having arthritis can affect your vision and dental health. Sometimes, the effects of the disease or medication side effects may cause dry eyes and mouth. If you neglect your oral health or don’t keep arthritis inflammation under control, you may get gum disease and experience tooth loss. For people with certain kinds of arthritis, inflammation can lead to an eye condition called uveitis, and if untreated, blurred vision or vision loss. That’s why proper dental and vision care are so important. Before you see a dentist, optician (who provides general eye care and identifies vision-related health problems) or ophthalmologist (who diagnoses and treats eye disease, prescribes medications and performs eye surgery), ask these questions:

    • Which dental and eye health conditions are covered by my major medical plan?
    • Are routine screenings and preventive treatments only covered by a stand-alone plan?
    • Do I need a referral from my rheumatologist for the dental or vision service in order for my care to be covered by my major medical plan?
    • Is the provider in my network?
    • What’s my copay or coinsurance for each dental or vision service? How much more will I pay for out-of-network services?
    • What are my deductibles?
    • Is there a limit on the number of visits or total expenses per year the plan will cover?
  • Imaging and Laboratory Tests

    From X-rays to magnetic resonance imaging (MRIs) to ultrasounds, your health care team will use different tests to diagnose and manage your arthritis and medication side effects. Here are a few questions to ask:

    • Is there a limit to the number of lab and imaging tests or expenses in a plan year?
    • Are there any limitations or restrictions on monitoring and follow-up tests?
    • Do I have to use a specific lab or imaging center?
    • Is the lab or center that my doctor refers me to in the network?
    • What are the costs for using an out-of-network lab? Do I need preauthorization?
    • Do I need to confirm if the imaging professional (radiologist) is in my network? What do I do if he or she is not?
  • Non-Physician Specialist Care and Complementary Therapies

    Physical therapists, occupational therapists, dieticians, and chiropractors are some of the non-physician specialists that provide health services to people with arthritis. Natural therapy providers (such as massage therapists and acupuncturists) can help improve pain and function. Here are a few questions to ask before getting these services:

    • Is the service covered?
    • Is there a limit on the number of visits per year?
    • What’s the copay or coinsurance?
    • Do I have to meet the deductible before these services are covered?
    • Is the provider in the network?
    • Do I need a referral?
    • Does the provider balance bill?
    • Do I need preauthorization for the service?
  • Mental Health

    People with chronic illness, such as arthritis have higher rates of depression and anxiety than those without chronic illness. These challenges can affect symptoms, such as pain and fatigue. Under the Affordable Care Act, mental health is considered an essential benefit and must be covered under your medical insurance.  However, most of the mandated services are screening services, so it’s important to read your insurance plan booklet carefully to determine what treatments are covered.

    There are a few exceptions with existing insurance plans. Grandfathered plans, self-funded plans and some union-based plans are excluded from the preventative health benefit ACA mandate.

    Here are a few questions to ask:

    • Are diagnostic or screening visits covered as a preventative health benefit?
    • What treatment services are covered?
    • What are my deductible, copay or coinsurance?
    • Do only certain diagnoses qualify for coverage?
    • What types of providers are included in my network – psychologist, psychiatrist, licensed professional counselor, clinical social worker?
    • Am I limited to the type of therapist I can access?
    • Do I need a referral?
    • Do I need preauthorization?
    • Is there a limit with how much time a therapy session can last?
    • Is there a limit for number of visits per week?
    • Does my therapist have to prove improvement for the sessions to be covered?
  • Surgery

    Some people with arthritis may end up needing joint surgery to alleviate pain and restore joint function. Here are a few questions to ask:

    • Is the surgeon, surgery center, hospital, anesthesiologist or rehabilitation center in-network?
    • Which procedures are covered?
    • Do I need pre-authorization?
    • How many hospitalization days are covered after surgery?
    • Is in-patient rehabilitation covered?
    • Is out-patient rehabilitation covered?
    • Is there a limit to expenses for rehabilitation services?
    • What are my copay, coinsurance and deductible?
  • Medical Devices, Mobility Aids and Orthotics

    To protect and support your joints, as well as maintain and improve your mobility, you may need a variety of devices and mobility aids. Here are some questions to ask:

    • Are custom splints and orthotics covered?
    • Are crutches, wheelchairs or walkers covered?
    • Is home equipment (like bath stools, commodes, grab bar installation) covered?
    • Do I need a prescription or referral?
    • Do I need pre-authorization?
    • Do I have to use specific service providers?
    • Is the an annual expense limit or a limit per type of device/aid in a plan year?
arthritis foundation prescription for access
arthritis foundation prescription for access