End of Year Insurance Considerations for PAH Patients

insurance considerations in pah

The end of the year brings many celebrated happenings. It is a wonderful time of year to celebrate coming together with family and friends.  It also brings a much less celebrated event…open enrollment.

Open Enrollment

We are currently in the middle of Medicare/Medicaid open enrollment which began October 15th and will end December 7th. Coverage chosen during this time will start January 1. During open enrollment, you can change your Medicare Advantage or Medicare Part D (Prescription Drug) plan. Many private insurances plans such as those offered by employers also have an enrollment period and new benefits starting in January.

Do I Have to Enroll in a New Plan?

If your current Medicare plan is being offered next year you do not need to enroll in a new plan. Check with your employer if you are on private insurance to see if your current benefit selections will apply next year or if you need to complete a new enrollment. Your current plan may have some changes for next plan year. This is the only time of year that you can select a new plan without a major life event change so read through the new benefits being offered by your plan and make sure they still cover your needs.

Physicians also change which insurance plans they are contracted with or are “in-network” with. Make sure to double check that your PAH care team will remain in-network with your current plan or are in-network with a plan you are considering. Out-of-network fees can add up very quickly.

All Medicare Part D plans and private insurance plans with prescription benefits have a different formulary or list of medications that they cover. Each medication is covered at a different tier level. The higher the tier the higher the member’s financial responsibility will be for that medication. For example, a Tier 1 medication may have a $20 copay while a tier 3 medication has a $100 copay. Review the drug formulary for next year and make sure your Pulmonary Hypertension medications are on it and covered.


There are several different types of insurance plans. You may see an option for an HMO or a PPO. An HMO (Health Maintenance Organization) is a plan that has a specific group of physicians within a closed network. Many times, HMOs have a lower premium (the price per month you pay out of pocket) but a limited number of physicians and specialists in the network. An HMO plan requires that members be assigned a PCP (Primary Care Provider) that is in their HMO and that PCP makes all referrals to specialists. The PCP acts as a gate keeper and directs patients to appropriate specialists.

A PPO (Preferred Provider Organization) is another option. These plans usually have a higher premium and a larger network of physicians that are in network with the insurance company but not necessarily with each other. Referrals from the PCP are not necessary prior to seeing a specialist.

It is important to pick the plan that fits your current needs. If a lower premium is a priority for you or if you have a PCP that you already see for all of your healthcare needs an HMO may be the right option. If you would rather pay more money each month but see a specialist when you choose then a PPO could be the right fit.

Make the Most of Deductibles You Have Already Met

Deductibles and out of pocket max amounts start over at the beginning of each plan year. The deductible is the amount of money the patient has to pay out of pocket before insurance will start picking up a larger portion of the bill. Many preventative tests and services such as an annual wellness check have a $0 copay and don’t require that a patient meets their deductible. Tests that are important for monitoring and diagnosing PAH such as echocardiograms or right heart catheterizations are not considered preventative. If you have met your deductible it may be a good idea to work with your PAH specialist to discuss what tests they want in the next several months and see if you can schedule them prior to January 1.

Bring Your New Insurance Card to Your Doctor’s Office

Inform all of your physicians of your new insurance plan as soon as you receive your new card. This will allow them to work quickly once January 1 comes to obtain authorizations for appointments, tests and medications. Bring your card to the doctor’s office so they can make a copy or scan it as it can be difficult to read all of the information the office will need to submit a claim. Many financial assistance programs will also require a new application for the new year to continue to offer support for expensive medications, etc.