Insurance Tips
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.
- All quick-relief medications and many long term control medications need to be taken with a spacer/valved-holding chamber. 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 and where you need to pick them up: pharmacy or DME. If you have Michigan Medicaid insurance, 4 spacers/valved holding chambers are allowed per year at the pharmacy without a prior authorization, and covered devices can be found on the common formulary.
- 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 through a process known as prior authorization. If you have Michigan Medicaid insurance, medications are listed on the common formulary.
- Asthma Care Coverage Report: The American Lung Association tracks seven areas of guidelines-based asthma care coverage in state Medicaid programs.
Questions you may want or need to ask your insurance provider:
Call your insurance company to get answers to your questions (the number is on the back of your card.) Ask for Customer Service and also ask to talk with the Disease Management or Case Management Department.
- "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 educator 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 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 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.
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