Insurance
PSC Partners reminds patients and caregivers to understand what their health insurance covers thoroughly. 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.
COBRA coverage is available if you change jobs or lose your coverage, which is attached to employment. 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 so that when you call the carrier, you can review the applicable sections and 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 state insurance regulations and laws. 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. Select the "Learn How to Apply for Coverage" icon from the home page.
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, having a baby, or qualifying 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 with high co-payments or 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.
Needymeds.org and GoodRX are great sources.
Financial Aid: You can discuss this with your medical center if you need financial assistance. 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.
Knowing how to contact your local and state legislative representatives may also be beneficial. You can discuss your situation with them, and 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.
Legal
Advance Health Care Directives
The Advance Health Care Directive (AHCD) is a way to make your healthcare wishes known if you are unable to communicate. The AHCD tells others what kind of medical treatment you would want, or would not want, if you had a serious illness or injury. The AHCD also lets you name someone you trust to speak for you if you cannot speak for yourself; this person is described as your “agent” or “surrogate decision-maker.”
Everyone, age 18 and older, should complete an AHCD, as an accident or a chronic illness can affect any one of us. Your AHCD is only used if you are unconscious or too ill to communicate; at all other times, you will express your own decisions about your medical care.
Three things help you receive the type of care you would want during critical illness or near the end of your life:
- Completing an AHCD
- Talking about your wishes with your family
- Talking about your wishes with your doctor
The medical system is legally obligated to provide all medical treatments in an emergency, including cardiac resuscitation and advanced life support, unless there has been legal documentation, such as an AHCD. Both your physician and your "surrogate decision-maker" must try to provide the type of treatment they believe YOU would choose in that situation.
Legal Issues and Self-Advocacy
Many hospitals and physicians today ask, upon admission, if you have handled legal matters such as setting up a health care power of attorney, drafting medical directives, deciding upon organ donation, and related topics.
These topics have become easier to discuss in the past few years with families and friends. There is a wealth of resources available to develop these documents:
- A power of attorney is a formal document that allows someone else to act as your legal representative and to make binding decisions on your behalf.
- A medical power of attorney, also known as a healthcare proxy, is one type of healthcare directive that communicates your wishes in case you are not able to express this information due to a medical emergency or situation.
- A will is a legal document that outlines what you want done with your property after you die.
- A medical directive lets family and the medical teams know what treatments you want or don’t want. It is also called an advance directive.
There are many sources for developing these documents. A lawyer can help you put them together. Most hospitals provide medical forms to patients. The internet can provide some forms, but be sure they will be legal in your state.
- CaringInfo (formerly Caring Connections) offers free, state-specific Advanced Health Care Directive (ADCD) forms that you can download in English or Spanish. Call 800-658-8898 or email caringinfo@nhpco.org.
- An online, free advance health care directive site is My Directives.
- Prepare for Your Care walks you through the medical aspects of your preferences, and is available in Spanish and English.
- “Five Wishes" is another popular AHCD (cost: $5)
Organ Donor: If you want to be an organ donor, tell your family and your caregiver(s) and indicate your wish via a driver’s license or other document. Click here for a site that will help you designate your wish to be a donor. State departments of motor vehicles, division of driver license, are the locations where most potential donors register through driver renewals. Some states have donor registries.
The AHCD may look long, but it is actually not hard to complete. There are key items to complete:
- Who can speak for you if you cannot speak
- Identify if you want life-sustaining treatment if you are terminally ill, or in a coma, and not expected to recover
- Organ and tissue donation instructions
- Your signature
- Two witnesses whose signature validates that you signed the form
- You can personalize your AHCD to include preferences for quality of life considerations, physician preference, etc.
When you have completed your AHCD, give copies to:
- Your doctor to place in your medical record
- Your agent or surrogate decision-maker
- The hospitals where you are receiving medical care
- A trusted family member who can keep a copy of your AHCD in a known location, and
- Be sure to talk with your family about your wishes and values
The Conversation Project offers tools and videos to help you discuss your medical wishes with your family and close friends.
Update
Check your document periodically, as your circumstances, wishes, and family situation may change. Find out if your state requires updating specific documents. Older advance directives may not be as comprehensive as more recent AHCDs.
- Older forms of advance directives include Living Wills and Natural Death Acts. These forms state that you do not want life-sustaining treatment if you become permanently unconscious or suffer from a terminal disease. Many states no longer promote using these forms and encourage completing an AHCD to state your wishes and name your surrogate decision-maker or agent.
- Doctors may recommend an additional form, such as a POLST (Portable Medical Orders), to clarify specific medical wishes for the medically frail or seriously ill.
Helpful Insurance Tips from a Caregiver
- Document all conversations with insurance representatives, including name, title, telephone number, date, and conversation details.
- 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 must be done before 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 rescinding a “denial of coverage.”
- Know your coverage for travel. Obtain enough medications to cover your vacation, plus a few extra days. It can help to explain your travel plans to 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, purchasing it when making reservations is optimal.
- Carefully evaluate travel insurance coverage for pre-existing conditions.
