Are You Living with Endometriosis in the US? (6.5 Million Women in Total) Know it’s disruptive & Delaying Diagnosis Can Take Years (Achieve A Diagnosis Takes Years!)
Finding an effective treatment may take four to 11 years on average, which can be frustrating.
Diagnosing and treating endometriosis can be both physically and financially draining; all those doctor visits, treatments, and procedures can quickly add up even with health insurance coverage.
If you suspect or know you have endometriosis, or need insurance plans for it, here are nine questions you should ask before choosing a plan. Make sure you get the optimal health coverage to keep costs and headaches to a minimum.
1. Is My Healthcare Plan Compliant With Obamacare?
The Affordable Care Act, also known as Obamacare, established rules governing health insurers that included coverage for contraceptives and no increased premiums for women than for men. If you purchase health insurance through Healthcare.gov (federal Health Insurance Marketplace) or state marketplaces in your state, these protections will likely apply; otherwise you might not. Plans bought outside these marketplaces might not cover everything as advertised or even deny preexisting conditions coverage like endometriosis diagnosis!
2. What healthcare providers (HCPs) do you consult? Do you rely on one or more HCPs – such as primary care physicians and specialists, clinics, or hospitals – for care? If there are endometriosis specialists you trust who are within any proposed insurance plans’ network of HCPs to treat members, make sure their availability can be confirmed prior to making your choice.
3. Does the provider network of the health plan you’re considering include endometriosis specialists?
Not every HCP is experienced at diagnosing or treating endometriosis; only some specialists offer laparoscopic surgery as an effective form of endometriosis treatment. Even if the HCPs you’re satisfied with are part of your health plan’s network, check who else might offer alternative approaches should your symptoms change in any way.
4. How flexible would your plan be if you needed a new HCP or want to visit an out-of-network provider or facility? Review its policy when needing an HCP who falls outside its network or visiting facilities not included within it. If the healthcare providers you’re seeing currently aren’t meeting your needs, switching or trying new specialists might be in order. Even if these healthcare professionals don’t fall under your health plan’s network, reimbursement may still be available so that you can access them. As with health maintenance organizations (HMOs), certain health plans (like HMOs) don’t offer assistance for paying out-of-network healthcare professionals (HCPs). Even if you are completely satisfied with the care you are receiving, consider making sure that there is some flexibility within your plan so you may see specialists from outside their network when necessary.
5. Are common endometriosis treatments covered, and what will the costs be for their provision?
Beginning your endometriosis treatment often starts with over-the-counter painkillers purchased independently. Once these are in place, your healthcare provider may suggest hormone birth control or progestin alone as solutions. According to Affordable Care Act regulations, medications used in treating endometriosis will likely be covered. But depending on the extent of your endometriosis and what treatments have already been tried, those medications may not provide enough relief. Make sure that your health plan covers long-term hormone therapy, hormonal IUDs and therapies for pain management as well as surgery (such as laparoscopic procedures to remove endometrial implants or cut pelvic nerves to relieve discomfort), procedures to remove your ovaries (oophorectomy) or uterus (hysterectomy). If necessary.
Learn the definitions of key health insurance terms.
Review your coverage for these treatments carefully by considering which providers are covered, costs involved in copayments/coinsurance payments, step therapy requirements for medication plans – for instance requiring you to try less expensive alternatives first before the plan will cover more costly ones, and only then if those less costly drugs don’t work! For medication plans requiring step therapy (ie testing of less costly ones before going onto more costly ones if those first don’t work).
6. What’s Your Policy Regarding New Treatments As They Become Available? Women living with endometriosis frequently wish for relief; will your health plan cover new therapies as they become available?
As it’s impossible to know for certain whether or not a treatment that has yet to become available would be covered, inquire into your plan’s policy on reviewing and approving new treatments, or check health plan ratings to see how other people rate these health plans on factors like ease of accessing care.
7. What Is My Deductible? Deductibles — healthcare costs you pay before your health insurance begins covering them — have become increasingly commonplace, meaning it is likely you’ll need to cover any services you use until insurance picks up its share. If you are likely to use more costly procedures like removal of endometrial tissue (which often needs repeated) out-of-pocket until meeting your deductible threshold; so be sure you have sufficient funds available in order to do so if this becomes an issue; higher monthly premiums could cost more, depending on how often such procedures need be paid out before insurance starts paying its share of costs compared with higher deductibles which might make it worthwhile depending on usage rates of services needed and costs involved.
8. What Is Coinsurance? mes Coinsurance can be one of the least-understood aspects of health plans, but failing to comprehend this cost could take a substantial bite out of your budget. Coinsurance refers to the percentage of medical bills you owe after meeting your deductible; for example if endo pain sends you straight to an ER where the bill totals $10,000 with 20% coinsurance you would only owe $2,000. Being aware of that percentage allows you to plan for potential expenses that arise more easily.
9. What Is an Out-of-Pocket Maximum? Health plans may limit how much out of pocket expenses they require you to pay annually, known as the out-of-pocket maximum (OOP Maximum). On Healthcare.gov Marketplace plans, OOP Maximum limits are set by the government – in 2023 this cap cannot go above $9100 for individuals and $18,200 for families (this doesn’t mean all plans will use this limit; just an upper limit they are allowed to use). When you compare plans this figure represents what total amount could potentially come out of pocket each year including deductible payments, Copayments, Coinsurance (premiums don’t count towards OOP Maximum calculation).