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 that 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 you are unable to afford COBRA coverage, you would be eligible for coverage under the Affordable Care Act. For more information, please see www.healthcare.gov.
Prescription Coverage: Understand your prescription coverage as well. Some policies prefer certain retailers. Some PSCers prefer a mail order pharmacy, which may be available through your coverage. Learn how to use the system for greater savings and the ability to receive up to a three month medication supply. You will need to build in ordering and processing time when re-ordering your medications with a mail order prescription system.
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, identification 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 your policy, checking for changes in coverage, deductibles, etc.
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. Visit the Health Insurance Resource Center. Look in the upper left corner and click on "Your state" for available coverage in your state. 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.
Medicaid: If you have questions about Medicaid programs or services, or need help applying for Medicaid coverage, visit Medicaid.gov. From the home page, select the "Learn How to Apply for Coverage" icon.
For additional information about "Who is Eligible for Medicaid", click here. On this website you can visit the "Health Insurance Marketplace", if you have life changes like losing health coverage or having a baby, or if you qualify for Medicaid or CHIP.
You may want to ask a Medicaid caseworker about:
- Medicaid for persons who are working, but are low income
- Temporary medical disability
- Medicaid for persons who had SSI, SSDI and are returning to work (maximum income levels apply)
- Temporary medical disability
- Medicaid “Spend down” programs
Sometimes local health departments have insurance assistance plans.
Partnership for Prescription Assistance (PPA): You may want to contact a PPA for prescriptions that have high co-payments, or have a maximum limit. Some companies deliver the medications to your doctor, and some provide a special card for the medications to be filled at the pharmacy.
Financial Aid: If you need financial assistance, you can discuss this with your medical center. Often financial counselors will work with you on managing coverage if you are between policies, or have other difficulties. The financial counselors can help with assistance programs. You can also ask about their charity care program.
It may also be beneficial to know how to contact your local and state legislative representatives. You can discuss your situation with them. They may be able to help you.
If you face a transplant and have limited financial resources, click here for a site listing organizations that may help.
Helpful Insurance Tips from a Caregiver
- Document all conversations with insurance representatives, including name, title, telephone number, date, and details of conversation.
- If you have a case manager (or care manager) through insurance, obtain the case manager’s name, telephone and fax number, and stay in contact with them 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. You may want to ask for written confirmation of the insurance authorization. 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, if needed in the future.
- Ask your doctor to document medications that were not effective or not tolerated in your clinic notes (electronic medical record)
- 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 can be important.
- 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. It can help to explain your travel plans with the pharmacy. Carry medications in their 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.
- Carefully evaluate travel insurance coverage for pre-existing conditions.
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