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Insurance Issues

Insurance Issues

These days, insurance coverage is more complicated than ever. And in the future, the situation will change yet again.

PSC Partners reminds patients and caregivers┬áthat they need to understand thoroughly what their health insurance covers. If you have a health insurance policy, read it carefully and know its relevant areas for your particular situation. If you don’t understand something, ask about it.

Employment and insurance: If you change employers or if your employer changes carriers, read the new policy so that you understand it. Keep your human resources department apprised of your satisfaction with the policy. They may have clout with the insurer in untangling some circumstances. Understand which health care providers are allowed under your new plan, as they may not be the same as those under your last policy.

If you change jobs or lose your coverage, which is attached to employment, COBRA coverage is available. This covers you for up to 18 months, although the entire cost would be borne by you, not shared with your employer. COBRA policies tend to be high priced because the former employee must pay what the employer would have paid, in addition to the employee’s regular payment.

If health insurance lapses while you are between jobs your health coverage situation becomes more complicated. You may have to re-qualify for a new policy if you have a pre-existing condition, which may take several months, or longer.

Prescription coverage: Understand your prescription coverage as well. Some policies prefer certain retailers. Find out if a mail order pharmacy is available through your coverage and will handle your meds. Learn how to use the system for greater savings. Our members have found they need to build in ordering and processing time when working with a mail order prescription system. They must keep up with their medication supply and order new supplies well ahead so they don’t run out.

Communicating with insurers: Keep your health insurance policy binder close at hand so that when you call the carrier, you can review the applicable sections and can reference them during your conversation, Keep copies of your Explanation of Benefits statements as well.

When you call the insurer, always get the name, ID number, and phone number of the person you talked to. Make summary notes of the discussion and document the date and time of your conversation. Check your own state’s regulations to learn how long you need to keep these records. In some states the carrier can retroactively deny claims up to a certain number of years.

Policy review: Each year review the policy; often changes are made with little fanfare. It’s your job to know what and how the changes affect you. Know your spending caps, if any, as these can change, too.

State resources: Know how to reach the division of your state government that regulates insurance and how to file a complaint with them. In some states this would be the insurance commission.

Determine if your state has a high-risk health insurance pool and if you qualify to use it. The Health Insurance Resource Center can be reached by clicking here. http://www.healthinsurance.org/risk_pools. The organization’s website has explanations of risk pools, and offers links to each state’s insurance risk pool.

Learn how to access the state regulations and laws for insurance. Check state legislative websites for pending laws and related registers for new or proposed laws and regulations. Often this information is on websites that are updated periodically.

If Medicaid covers you, know how to review information from the state agency that handles this coverage. Many states will post descriptions of the different forms of Medicaid that they have available. These could include:

  • Traditional Medicaid
  • Medicaid for pregnant women and children
  • Medicaid for the working low income (Primary Adult Care)
  • Medicaid for persons coming off of SSI, SSDI and returning to employment (maximum income levels apply)
  • Supplemental insurance for those receiving Medicare (QMB)
  • Premium based Medicaid for children ($50-$70 monthly)
  • “Spend down” programs for those with high medical costs: when your bills reach a certain amount then you are eligible for assistance, and
  • Temporary medical disability.

Sometimes local health departments have insurance assistance plans.

Patient Assistance Program (PPA): PPAs for prescriptions have high co-pays, or have a maximum limit. Needymeds.org is a great source for these and often even has the forms that your doctor can fill out to get the medication for you. Click here to go to that site. http://www.needymeds.org. Some companies deliver the meds to your doctor and some provide a special card for the meds to be filled at the pharmacy

Financial aid: File for financial aid through your medical center. Often financial counselors will work with you on managing coverage if you are between policies or if similar situations occur. The counselors may be knowledgeable about assistance programs. Hospitals that receive federal funds are required to offer some charity care and you may need to pursue this option with them. They may not offer it unless asked.

Finally, know how to contact your local and state legislative representatives and talk to them. Often they can cut red tape.

Research this topic regularly as things are always changing.

If you face a transplant and have limited financial resources, click here for a site listing organizations that may help.


Personal Story

Helpful insurance tips

Document all conversations with insurance representatives, including name, title, telephone number, date and details of conversation.

Ask for written confirmation of authorization, payment approval, etc.

If you have a case manager through insurance, obtain the case manager’s name, telephone and fax number, and stay in contact with him or her as necessary (case managers can be a wonderful resource and very helpful).

Before any test or procedures, validate insurance approval of the procedure, CT scan, etc., including the physician and the location of the procedure. Know and follow any preparation that needs to be done prior to the procedure (nothing by mouth, contrast material, whether to take your usual medications, etc.) Note: some insurance companies only cover a procedure done at a specific location with a specific physician.

With any change in coverage by your insurance company, check if your medication coverage has changed.

Mail order medications are often less expensive.

Keep track of medications you have tried and either could not tolerate or if the medication was not effective (known as “tried and failed,” due to intolerance or non-effectiveness of medication). Document medication name, dosage changes and dates. This sets the stage for insurance coverage of “non-formulary” medications.

Keep good records and ask your doctor to document in your clinic records, medications that were not effective or not tolerated.

Obtaining “second opinions” or “coverage out of area/out of group” can be challenging. The process is different for different insurance plans. Learn what your insurance requires and be persistent. Know that within one type of insurance, there is variability in what each policy covers. Again, research and persistence pays off.

You can challenge the insurance company if they refuse to authorize something; you will need to obtain and understand the company’s procedure for how to rescind a “denial of coverage.”

For travel, know your coverage. Obtain enough medications to cover your vacation, plus a few extra days. Carry medications in original bottles. Carry your medications in a carry on bag, not in your luggage. Airlines will allow you to carry on syringes for insulin, liquid medications, etc. Package the medications in a plastic bag so they can be viewed during the check-in process.

If obtaining travel insurance, it is optimal to purchase it when making reservations.

Evaluate insurance coverage of any pre-existing conditions.

Joanne H.