Uterine fibroids are extremely prevalent, with over three out of four women developing them at some point during their lifetimes. While not always manifesting symptoms, one-quarter to one-half of cases involve symptoms caused by fibroids causing heavy and long-lasting periods, pain in the pelvic floor during sex, frequent urination, constipation or lower back pain as possible side effects.

Diagnosing and treating illness often takes years. You may visit multiple healthcare providers (HCPs) during that period and try numerous treatments, which can become increasingly expensive – even with health insurance coverage.

Most Americans’ financial responsibility for medical bills comes directly out of their pockets through copayments, coinsurance and deductibles. When you know you require treatment for something such as fibroids, such as anticipated costs of different insurance plans. When selecting health coverage policies to minimize costs while increasing coverage; consider these nine questions when making decisions that best serve your needs.

1. Does Your Healthcare Plan Comply with the Affordable Care Act (ACA)? When reviewing health insurance options, one of the first things to check for compliance with the Affordable Care Act (ACA), commonly known as Obamacare. This protects women from being charged more simply due to gender or preexisting conditions if purchased outside state or federal Health Insurance Marketplaces such as Healthcare.gov; these individual plans do not need to meet all ACA compliance standards and could deny coverage entirely or for specific issues like fibroids.

2. What healthcare providers (HCPs) do you see? Do you rely on one or more primary or specialty care providers, clinics, or hospitals for treatment? If you already have one in mind, ensure they participate with any health insurance plan being considered – check the provider directory to confirm.

3. Does the provider network include experts with experience treating fibroids?
Not every health care professional knows how to treat fibroids effectively, so if this is a specific condition for which you require assistance, be sure that your health plan network offers HCPs who possess relevant expertise.

4. Are You Open to Change in Regards to Healthcare Professionals (HCPs) and Facilities (FCFs)? If you want to try a different HCP or facility than what is typically available to you, first verify with their specific health plan — not simply the insurance provider — whether they are part of it and in-network with it; not all HCPs see members from all plans, even within one insurer’s umbrella plan.

Also consider out-of-network benefits. In some plans (particularly HMOs), seeing an HCP who does not participate with your plan might just cost more; on others (like an HMO), 100% may apply or you could just have to see whomever the health plan allows for treatment.

5. Are the commonly available treatments for fibroids covered, and how much will be owed in fees for them?
Not every patient with fibroids needs treatment. But if symptoms occur, there may be options available. When selecting your health plan, make sure it covers these treatments – this could include over-the-counter pain relievers that you’ll typically pay for yourself on most plans or birth control pills that must be covered under ACA-compliant plans.

Some women require prescription medications; certain health plans require them to first try less-expensive ones before covering more costly ones (known as “step therapy”). Hormonal IUDs can sometimes provide relief; be sure to find out whether those are covered and at what cost. Other fibroid treatments include embolization (a process that causes fibroids to shrink), embolization procedures or surgery aimed at myomectomy or hysterectomy to remove fibroids or the uterus respectively.

Each of these treatments will carry its own costs — either copayments or coinsurance payments, or, in cases with deductibles, first meeting them before coverage kicks in.

6. What’s the policy on covering new treatments as they become available? Aside from existing therapies that relieve symptoms or surgically remove fibroids, new therapies are constantly coming out on the market – it can be hard to know whether your new health plan will cover them when they become available. Most health plans require evidence that new treatments are superior, often necessitating rigorous compliance for more expensive ones. But you can get an idea of the health plan’s responsiveness by seeing whether they cover other relatively recent treatments or review its policy on approval of new medications. Health plan ratings also offer important insight.

7. What Is a Deductible? Most Americans now carry health insurance that requires them to meet a deductible; until that deductible has been reached (paid), 100% of your medical costs (even services covered by your plan) must be covered by you alone. Once met, most costs are taken over by insurer but typically there remains some cost (copayment or coinsurance) remaining with you as part of a copayment or coinsurance payment agreement.

Your deductible usually decreases with each premium payment made and vice versa. If you can afford a higher payment each month, it could make life easier when services become necessary and large bills come due. On the other hand, having financial resources to make out-of-pocket payments until meeting your deductible may save money in the long run.

8. Coinsurance is one of the least understood health plan costs, yet can quickly add up. Coinsurance refers to the percentage of medical bills you owe after meeting your deductible – for instance if you need surgery to remove fibroids that costs $10,000 with 20% coinsurance this would come out of your wallet as $2,000 out of pocket payment.

9. What is an Out-of-Pocket Maximum?

Health plans may impose an out-of-pocket maximum, or “out-of-pocket limit”, on you annually for covered services. The government sets this amount annually through Healthcare.gov – in 2023 the out-of-pocket max limit in Marketplace plans cannot go higher than $9100 for an individual and $18,200 for families (this doesn’t mean every plan will use that cap; just that this maximum cap can be used). This maximum includes all annual costs such as deductible payments, copayments and coinsurance (premium payments do not count toward this total). When comparing plans it’s important to check which plans have caps attached when comparing plans before making your choice decision!


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