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PatientAdvocateFoundation
(Organization (Verified) )| Communities: Breast Cancer | Answers: 39 |
| Member Since: Apr. 2011 |
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Organization Info
Our Mission: To provide effective mediation and arbitration services to patients to remove obstacles to healthcare including medical debt crisis, insurance access issues and employment issues for patients with chronic, debilitating and life-threatening illnesses nationally.
Organization address:
421 Butler Farm Road
Hampton, VA
23666
Contact phone:
800-532-5274
Webpage:
www.patientadvocate.org
PatientAdvocateFoundation Activities
Finding resources for living expenses are linked the needs of the person as well as demographics, household size, income and assets. There are ongoing programs such as LIHEAP ( www.liheap.com) that offers qualified individuls support toward heating and energy bills; LifeLine (www.lifeline.gov) for telephone; SNAP (http://www.snap-step1.usda.gov/fns) or SHARE food program (enter your state in google to find location) for food assistance; HUD.gov provides leads to reduced rentals, section 8 and other housing support. For one time support sometimes community action agencies, social services, local and/or national non-profits, disease specific organizations as well as churchs may be of support. I encourge you to utilize a Resource Directory athttp://www.patientadvocate.org/resources.php for a individualized list of resources based on your individual neeeds.
As you outlined, most alternative treatment is not covered by insurance, however be sure to consult with your plan and/or review your plan language before paying out of pocket. If your plan does not cover these services there are few resources to help financially. I would suggest finding a resource that will help offset the cost that you are already paying to help balance the added cost. Below are a few resources depending on your location and need may be of help.
The National Center for Complementary and Alternative Medicine has fact sheet provides a general overview of related topic and suggests sources for additional inforation athttp://nccam.nih.gov/health/financial.
The Annie Appleseed Project ( www.annieappleseedproject.org)provides information, education, advocacy, and awareness for people with cancer, their family and friends.
There are very little resources for alternative care, below are some resources that offer free or reduced services.
The Charlotte Maxwell Complementary Clinic (www.charlottemaxwell.org)is located in Oakland, CA and offers free complementary alternative medical treatments to low-income women with cancer.
The Melonhead Foundation, Inc (www.melonhead.org) supports the needs of children and their families who are seeking alternative methods of healing.
Pacific College Acupuncture and Massage Clinic (www.pacificcollege.edu) offers low-cost treatment for a wide range of ailments using acupunture and other healing modalities of Traditional Oriental Medicine. Locations are in San Diego, New York and Chicago.
As you outlined, most alternative treatment is not covered by insurance, however be sure to consult with your plan and/or review your plan language before paying out of pocket. If your plan does not cover these services there are few resources to help financially. I would suggest finding a resource that will help offset the cost that you are already paying to help balance the added cost. Below are a few resources depending on your location and need may be of help.
The National Center for Complementary and Alternative Medicine has fact sheet provides a general overview of related topic and suggests sources for additional inforation athttp://nccam.nih.gov/health/financial.
The Annie Appleseed Project ( www.annieappleseedproject.org)provides information, education, advocacy, and awareness for people with cancer, their family and friends.
There are very little resources for alternative care, below are some resources that offer free or reduced services.
The Charlotte Maxwell Complementary Clinic (www.charlottemaxwell.org)is located in Oakland, CA and offers free complementary alternative medical treatments to low-income women with cancer.
The Melonhead Foundation, Inc (www.melonhead.org) supports the needs of children and their families who are seeking alternative methods of healing.
Pacific College Acupuncture and Massage Clinic (www.pacificcollege.edu) offers low-cost treatment for a wide range of ailments using acupunture and other healing modalities of Traditional Oriental Medicine. Locations are in San Diego, New York and Chicago.
New answer by PatientAdvocateFoundation (Organization (Verified))
1
Answer |
3 months ago
Wheither you have outstanding debt or have not yet started treatment, call
the billing office of the hospital and ask if they have a hardship, charity or an indigent program. You will find that most public hospitals and faith-based facilities have a program. Be prepared to offer the facility details about your health and financial status.
There are many programs available to assist you with getting your medications. Many medications are available through patient assistance programs offered by the pharmaceutical companies. Each company has their own eligibility requirements and applications. You can visit www.needymeds.com or www.pparx.org for a complete listings of
all drugs available through these programs.
the billing office of the hospital and ask if they have a hardship, charity or an indigent program. You will find that most public hospitals and faith-based facilities have a program. Be prepared to offer the facility details about your health and financial status.
There are many programs available to assist you with getting your medications. Many medications are available through patient assistance programs offered by the pharmaceutical companies. Each company has their own eligibility requirements and applications. You can visit www.needymeds.com or www.pparx.org for a complete listings of
all drugs available through these programs.
New answer by PatientAdvocateFoundation (Organization (Verified))
1
Answer |
4 months ago
The Food and Drug Administration (FDA) considers generic drugs to be equally effective as brand names. It's imperative to be aware of what your doctor is prescribing for you and to, whenever possible, choose medications that are covered on the formulary. Medications classified as non-formulary are typically brand-name medications that have no available generic equivalent. They are usually in the third tier of prescription benefits and require the highest out-of-pocket expense. In some cases the medications may require prior approval by your insurance company. Typically the health care provider obtains this approval.
The formulary medication lists are regularly reviewed by a peer review panel of physicians and pharmacists appointed by the insurance company, and medications are added or deleted as deemed appropriate by this peer review process. Patients can reduce their costs by consulting the formulary, because covered medications require less out-of-pocket cost to the insured.
Some medications are selected for the formulary because they are the only available drug to treat a disease and are a substantial therapeutic advance. When there are multiple drugs available to treat a single condition, the insurance companies review the various options for optimal cost-effectiveness. Drugs may be excluded from the formulary if it is deemed ineffective or its safety is called into question in comparison to similar drugs.
If the medication being ordered is the only medication that your health care provider believes will be effective for you, you can request an exception to the formulary. In order to do this your health care provider can contact the Pharmacy Benefit Manager (PBM) for your insurance provider, or write a letter of medical necessity to request approval for you to obtain the requested medication.
Read more: Formulary Vs. Non-Formulary | eHow.comhttp://www.ehow.com/info_7753756_formulary-vs-nonformulary.html#ixzz2IALCyFpE
The formulary medication lists are regularly reviewed by a peer review panel of physicians and pharmacists appointed by the insurance company, and medications are added or deleted as deemed appropriate by this peer review process. Patients can reduce their costs by consulting the formulary, because covered medications require less out-of-pocket cost to the insured.
Some medications are selected for the formulary because they are the only available drug to treat a disease and are a substantial therapeutic advance. When there are multiple drugs available to treat a single condition, the insurance companies review the various options for optimal cost-effectiveness. Drugs may be excluded from the formulary if it is deemed ineffective or its safety is called into question in comparison to similar drugs.
If the medication being ordered is the only medication that your health care provider believes will be effective for you, you can request an exception to the formulary. In order to do this your health care provider can contact the Pharmacy Benefit Manager (PBM) for your insurance provider, or write a letter of medical necessity to request approval for you to obtain the requested medication.
Read more: Formulary Vs. Non-Formulary | eHow.comhttp://www.ehow.com/info_7753756_formulary-vs-nonformulary.html#ixzz2IALCyFpE
New answer by PatientAdvocateFoundation (Organization (Verified))
1
Answer |
4 months ago
Formularies are preferred drug lists, and the list should be readily available in your benefit information. Generally, this list of prescriptions extends to specific generic and brand-name medications that have already been approved by the FDA and are considered to be safe. The drugs on your formulary list are usually negotiated between the manufacturer and insurance company for special volume discounts. Some drugs on the formulary may require pre-authorization, be sure to refer back to your specific benefits.
The goal of the a drug formulary is to give physicians more information about alternative therapy, enhancing cost effectiveness and giving patients more access to information. Most formularies are chosen after being thoroughly reviewed by the insurance carrier and are placed on the preferred drug list because they are important therapeutically and/or are less expensive than other drugs with the same effect. Medicare introduced Specialty Tiers with Medicare Part D in an attempt to control the cost of drugs. Many insurance plans have adopted this model making less expensive drugs more accessible, and as the complexity and cost of the medications increase so may your co-payment.
The goal of the a drug formulary is to give physicians more information about alternative therapy, enhancing cost effectiveness and giving patients more access to information. Most formularies are chosen after being thoroughly reviewed by the insurance carrier and are placed on the preferred drug list because they are important therapeutically and/or are less expensive than other drugs with the same effect. Medicare introduced Specialty Tiers with Medicare Part D in an attempt to control the cost of drugs. Many insurance plans have adopted this model making less expensive drugs more accessible, and as the complexity and cost of the medications increase so may your co-payment.
New answer by PatientAdvocateFoundation (Organization (Verified))
2
Answers |
4 months ago
Medicaid is a federally mandated but state run program. Eligibility for Medicaid is determined by each state and takes several factors into consideration. There are many categories of eligibility and several different Medicaid programs. Please review all of the eligibility information and if you think you may be eligible, the best thing to do is apply. While different Medicaid programs have different eligibility criteria, in general four main criteria are used to determine eligibility.
• Income/Family Size: Both earned (wages from a job) and unearned income (Social Security Disability payments). Income limits are adjusted to account for the number of people in your family.
• Age: Eligibility criteria can be based on age. Certain programs are designed for people in specific age groups.
• Resources/Assets: Certain things you have are taken into consideration when determining eligibility. Different programs count different resources/assets.
• Medical Needs: Specific medical needs may determine your eligibility and they may also determine which program can best serve your needs. Some programs are designed to meet the medical needs of a targeted group such as the disabled or aged population.
To learn more about your state Medicaid program and other options available to you, visit www.Medicaid.gov
• Income/Family Size: Both earned (wages from a job) and unearned income (Social Security Disability payments). Income limits are adjusted to account for the number of people in your family.
• Age: Eligibility criteria can be based on age. Certain programs are designed for people in specific age groups.
• Resources/Assets: Certain things you have are taken into consideration when determining eligibility. Different programs count different resources/assets.
• Medical Needs: Specific medical needs may determine your eligibility and they may also determine which program can best serve your needs. Some programs are designed to meet the medical needs of a targeted group such as the disabled or aged population.
To learn more about your state Medicaid program and other options available to you, visit www.Medicaid.gov
New answer by PatientAdvocateFoundation (Organization (Verified))
1
Answer |
4 months ago
According to the Federal Trade Commission (FTC), the nation's consumer protection agency, family members typically are not obligated to pay the debts of a deceased relative from their own assets. What's more, family members – and all consumers – are protected by the federal Fair Debt Collection Practices Act (FDCPA), which prohibits debt collectors from using abusive, unfair, or deceptive practices to try to collect a debt.
Does a debt go away when the debtor dies?
No. The estate of the deceased person owes the debt. If there isn't enough money in the estate to cover the debt, it typically goes unpaid. But there are exceptions to this rule. You may be responsible for the debt if you:
• co-signed the obligation;
• live in a community property state, such as California;
• are the deceased person's spouse and state law requires you to pay a particular type of debt, like some health care expenses; or
• were legally responsible for resolving the estate and didn't comply with certain state probate laws.
If you have questions about whether you are legally obligated to pay a deceased person's debts from your own assets, talk to a lawyer.
Who has the authority to pay the deceased person's debt out of his or her assets?
The person named in a will who is responsible for settling a deceased person's affairs is called the executor. If there is no will, the court may appoint an administrator, personal representative, or universal successor, and give them the authority to settle the affairs. In some states, others (or other people) may have that authority, even if they haven't been formally appointed by the court.
http://www.consumer.ftc.gov/articles/0081-debts-and-deceased-relatives
Does a debt go away when the debtor dies?
No. The estate of the deceased person owes the debt. If there isn't enough money in the estate to cover the debt, it typically goes unpaid. But there are exceptions to this rule. You may be responsible for the debt if you:
• co-signed the obligation;
• live in a community property state, such as California;
• are the deceased person's spouse and state law requires you to pay a particular type of debt, like some health care expenses; or
• were legally responsible for resolving the estate and didn't comply with certain state probate laws.
If you have questions about whether you are legally obligated to pay a deceased person's debts from your own assets, talk to a lawyer.
Who has the authority to pay the deceased person's debt out of his or her assets?
The person named in a will who is responsible for settling a deceased person's affairs is called the executor. If there is no will, the court may appoint an administrator, personal representative, or universal successor, and give them the authority to settle the affairs. In some states, others (or other people) may have that authority, even if they haven't been formally appointed by the court.
http://www.consumer.ftc.gov/articles/0081-debts-and-deceased-relatives
New answer by PatientAdvocateFoundation (Organization (Verified))
1
Answer |
4 months ago
Your ability to qualify for a loan is based on many factors, such as your credit score, income, debts, assets, etc. One thing we would recommend you watch for would be possible discrimination based on your diagnosis. You should not see any different attitude than you would expect in general from a lender. Interest rates, processing fees, processing time, etc. should all be in line with any loan that is being offered to a person submitting an application to the specific lending institution.
Another option you may want to consider is getting a viatical settlement. A viatical settlement is when a terminally ill person sells his or her life insurance policy to a third party for a lump-sum payment. In return, the third party, who may be an individual investor or a special firm, takes over the premium payments on the policy. This would allow you to enjoy your money or pay down your debt with the cash. Viatical settlements vary greatly depending on whom you are settling with, your state (or the policy’s state), and the terms of your individual policy.
The viatical industry is regulated on the state level but there is no federal regulation that governs these settlements. If you are interested in being party to a viatical settlement, you can start with the state insurance commissioner’s office or check with your State Health Insurance Assistance Program (SHIP) office. If you are considering this option, the person who is buying your life insurance policy, known as the viator, becomes the new owner of the policy and is the beneficiary upon your death.
You will want to consult with a tax professional or attorney before making a final decision. There is a provision in the Health Insurance Portability and Accountability Act of 1996 (HIPAA), terminal patients are sometimes not even required to pay federal taxes on the proceeds from a viatical settlement.
Some other options you may want to consider:
• Check to see if your life insurance policy has an accelerated death benefit This is generally only a partial benefit, but would give you cash relief and would not be hard on your beneficiaries.
• Take out a loan against the equity in your house or against the cash value of your retirement funds or other assets that you may have. This will provide you with some funds, and it will not totally penalize your heirs.
• For medical treatment debt, think about going on a payment plan using Visa or MasterCard. Most people are very responsible about their charge cards. But you need to pay only the minimum and your doctors get paid. While this will penalize your heirs eventually, it will relieve your worrying and keep you from feeling guilty every time you see your doctors.
https://www.caring4cancer.com/go/cancer/financial/help-with-costs/viatical-settlements.htm
Another option you may want to consider is getting a viatical settlement. A viatical settlement is when a terminally ill person sells his or her life insurance policy to a third party for a lump-sum payment. In return, the third party, who may be an individual investor or a special firm, takes over the premium payments on the policy. This would allow you to enjoy your money or pay down your debt with the cash. Viatical settlements vary greatly depending on whom you are settling with, your state (or the policy’s state), and the terms of your individual policy.
The viatical industry is regulated on the state level but there is no federal regulation that governs these settlements. If you are interested in being party to a viatical settlement, you can start with the state insurance commissioner’s office or check with your State Health Insurance Assistance Program (SHIP) office. If you are considering this option, the person who is buying your life insurance policy, known as the viator, becomes the new owner of the policy and is the beneficiary upon your death.
You will want to consult with a tax professional or attorney before making a final decision. There is a provision in the Health Insurance Portability and Accountability Act of 1996 (HIPAA), terminal patients are sometimes not even required to pay federal taxes on the proceeds from a viatical settlement.
Some other options you may want to consider:
• Check to see if your life insurance policy has an accelerated death benefit This is generally only a partial benefit, but would give you cash relief and would not be hard on your beneficiaries.
• Take out a loan against the equity in your house or against the cash value of your retirement funds or other assets that you may have. This will provide you with some funds, and it will not totally penalize your heirs.
• For medical treatment debt, think about going on a payment plan using Visa or MasterCard. Most people are very responsible about their charge cards. But you need to pay only the minimum and your doctors get paid. While this will penalize your heirs eventually, it will relieve your worrying and keep you from feeling guilty every time you see your doctors.
https://www.caring4cancer.com/go/cancer/financial/help-with-costs/viatical-settlements.htm
New answer by PatientAdvocateFoundation (Organization (Verified))
1
Answer |
4 months ago
This is a situation we get asked on a daily basis. If your medical debt is through a hospital, you will need to contact the financial counselor or a social worker at the facility and find out if they offer any financial assistance. Most hospitals, especially non-profits, have assistance programs in place for low-income, uninsured, and under-insured patients. Some facilities call the program by different names, charity care or financial hardship programs, but you want to ask if they offer any financial assistance, do not worry about the name. There will be an application process where you will need to provide personal information such as household income in order to be screened for eligibility.
If you are approved for financial assistance, the hospital will notify the applicant of the discount or write-off amount they are able to provide. We suggest notifying other healthcare providers where you still have a balance due, that you were approved for financial assistance through the hospital and inquire if they would consider providing that same discount on your outstanding balance. Often times they will consider this discounted amount. After the providers have adjusted the accounts, if a balance remains, arrange a payment plan that is reasonable for your budget.
If you are approved for financial assistance, the hospital will notify the applicant of the discount or write-off amount they are able to provide. We suggest notifying other healthcare providers where you still have a balance due, that you were approved for financial assistance through the hospital and inquire if they would consider providing that same discount on your outstanding balance. Often times they will consider this discounted amount. After the providers have adjusted the accounts, if a balance remains, arrange a payment plan that is reasonable for your budget.
New answer by PatientAdvocateFoundation (Organization (Verified))
1
Answer |
4 months ago
We recognize that making a decision on the best insurance coverage for you and your family is a challenging task. The National Association of Insurance Commissioners (NAIC) provides these tips to help you make the best choice of the options available for you and your family.
Whether you are part of the 153 million Americans who receive health insurance coverage from an employer, the more than nine million self-employed, or the almost 14 million unemployed, tough economic times, rising medical costs and new laws related to healthcare reform make now a great time to reeducate yourself about health insurance.
If you receive health insurance through an employer, consider the following before selecting a coverage plan this year:
• Look closely for changes: Don’t automatically renew the option you had before; many employers are making changes due to rising costs.
• Take advantage of wellness incentives: Find out if your employer offers a wellness program that includes money-saving incentives for healthy behaviors such as exercising regularly or not smoking.
• Check out tax-free savings: In addition to your health insurance coverage, you may be eligible to open a Flexible Spending Account (FSA) or a health savings account (HSA). And don’t forget about dependent care savings accounts.
If you are self-employed or if your employer doesn’t offer coverage, you face unique challenges in finding and keeping health insurance, but you still have choices.
• Spouse plan: Check about being added to your spouse’s or domestic partner’s employer plan.
• Individual insurance: Consider shopping for private insurance. This option allows you to customize care to your lifestyle, health and budget. New Pre-Existing Condition Insurance Plans (PCIP) could help if you have had trouble qualifying for coverage in the past. Plus, recent tax law changes make it possible to deduct the cost of premiums from your taxable income.
If you are unemployed, within the past year you were likely forced to determine how, or if, to continue your health insurance. Now is a good time to review your decision. If you’ve been out of work for some time and your income has taken a significant hit, you or your family members might be eligible for Medicaid or the Children’s Health Insurance Program.
Health Insurance for Your Life Stage
In addition to your work situation, your family structure and lifestyle also have an impact on your health insurance needs. Find the right fit for you.
• Young Singles: If you’re a recent college graduate and just entering the workforce, this is likely the first time you’re making your own health insurance decisions. Of course you have questions. What’s the difference between an HMO and a PPO? How long can you continue coverage on your parents’ health insurance policy? NAIC has answers.
• Young Families: A new spouse or baby can significantly change your health insurance needs and costs. In short, it’s not just about you anymore. Consider these tips to ensure you and your growing family are covered.
• Established Families: As your family matures, so do your health insurance needs. From maintenance drugs and braces to insurance for your college student, it’s important to know the facts.
• Seniors: Now that your children are grown, it’s more important that you focus on your own health. Make sure you have the right coverage before and during retirement.
Many other special health insurance considerations come into play for domestic partners, single parents, military, and seniors who are raising grandchildren. Knowing your options helps you save time, money and frustration.
What is Open Enrollment?
Open enrollment refers to the period of time during which all members of your group health insurance plan have the opportunity to enroll in certain benefit programs. During an open enrollment period, insurance carriers are required to accept all applicants of the group without underwriting or evidence of insurability. Open enrollment is generally only held once a year. If you miss your company’s annual open enrollment, you likely will not be able to enroll in your employer-sponsored health insurance program until next year. Certain exceptions apply for new employees or employees with life changing events.
Make sure to check with your human resources department to see when your company’s open enrollment period begins and ends, and when your policy goes into effect, and can discuss your concerns with the selected insurance plan.
Read and Understand the Materials
There are many different types of major medical plans typically offered by employers. For help understanding the fundamental differences between preferred provider organizations (PPO), health maintenance organizations (HMO), point of service plans (POS) or indemnity plans, go to the NAIC insurance education Web site, www.InsureUonline.org and click on the life situation that most closely matches your own. The health section includes basic information about each type of program. Plan materials will detail which medical providers (physicians, hospitals, labs, pharmacies, etc.) are considered in-network and out-of-network. They will also detail how much the insurance carrier will pay under each type of plan.
Before making a choice:
• Check to see if your current physicians and area hospitals are in the plan’s network. Using network providers generally will save money on your health care.
• Check to see if spouses or dependents are covered. Some plans will cover spouses and other dependents, while other plans will not.
• Read all of the plan materials thoroughly. Doing so will tell you what your rights and responsibilities are under each plan.
• Review any pre-existing condition exclusions and prior authorization requirements in the plan materials.
• If you take prescription medications, check them against the list of approved drugs in each plan booklet.
• If any part of a plan is unclear to you, ask for help from your human resources department or the insurance carrier.
• If you are not satisfied with the answers to your questions, contact your state insurance department. Go to www.naic.org/state_web_map.htm for a link to your state insurance department’s Web site.
Compare the Cost and Coverage of the Plans Offered
In this uncertain market, it’s important to carefully evaluate your healthcare costs when making your annual enrollment decisions. While one option might have high monthly premiums and a low deductible, and another might have a low premium but more out-of-pocket expenses, it could be misleading which plan is best for you until you do the figures.
To pick the best coverage, first calculate your healthcare costs from recent years and try to estimate what your costs might be for the coming year. Don’t forget to include the cost of doctor’s visits, daily medications and any procedures you might be planning.
Next, make a list of the premiums, out-of-pocket expenses and benefits under each plan. Co-payments, deductibles and additional charges for wellness care or specialists (e.g. chiropractic care, cosmetic surgery, etc.) are examples of out-of-pocket expenses that you are responsible to pay. Remember, if you use a medical provider that is out-of-network, you will generally pay more out-of-pocket expenses. Include these fees in your calculations.
Finally, decide how much you can afford to pay. Other things to keep in mind:
• Check for any annual limits and prior authorization requirements.
• Some prescription medications have higher co-payments than others and they might vary from plan to plan. Mail-order options might be available for maintenance drugs at a lower cost to you.
• If your dependents have health insurance coverage through their employer, school or the Veteran’s Administration, compare their costs and benefits to the family plans you are considering to ensure that you choose the best plan for every member of your family. Make the same type of comparisons for any dental or vision care plans that you are offered.
Visit the NAIC's Special Section: PPACA & State Insurance Regulation for the latest news regarding healthcare reform implementation efforts.
Visit HealthCare.gov for information from the U.S. Dept. of Health & Human Services (HHS).
Resource: http://www.insureuonline.org/health_page.htm
Whether you are part of the 153 million Americans who receive health insurance coverage from an employer, the more than nine million self-employed, or the almost 14 million unemployed, tough economic times, rising medical costs and new laws related to healthcare reform make now a great time to reeducate yourself about health insurance.
If you receive health insurance through an employer, consider the following before selecting a coverage plan this year:
• Look closely for changes: Don’t automatically renew the option you had before; many employers are making changes due to rising costs.
• Take advantage of wellness incentives: Find out if your employer offers a wellness program that includes money-saving incentives for healthy behaviors such as exercising regularly or not smoking.
• Check out tax-free savings: In addition to your health insurance coverage, you may be eligible to open a Flexible Spending Account (FSA) or a health savings account (HSA). And don’t forget about dependent care savings accounts.
If you are self-employed or if your employer doesn’t offer coverage, you face unique challenges in finding and keeping health insurance, but you still have choices.
• Spouse plan: Check about being added to your spouse’s or domestic partner’s employer plan.
• Individual insurance: Consider shopping for private insurance. This option allows you to customize care to your lifestyle, health and budget. New Pre-Existing Condition Insurance Plans (PCIP) could help if you have had trouble qualifying for coverage in the past. Plus, recent tax law changes make it possible to deduct the cost of premiums from your taxable income.
If you are unemployed, within the past year you were likely forced to determine how, or if, to continue your health insurance. Now is a good time to review your decision. If you’ve been out of work for some time and your income has taken a significant hit, you or your family members might be eligible for Medicaid or the Children’s Health Insurance Program.
Health Insurance for Your Life Stage
In addition to your work situation, your family structure and lifestyle also have an impact on your health insurance needs. Find the right fit for you.
• Young Singles: If you’re a recent college graduate and just entering the workforce, this is likely the first time you’re making your own health insurance decisions. Of course you have questions. What’s the difference between an HMO and a PPO? How long can you continue coverage on your parents’ health insurance policy? NAIC has answers.
• Young Families: A new spouse or baby can significantly change your health insurance needs and costs. In short, it’s not just about you anymore. Consider these tips to ensure you and your growing family are covered.
• Established Families: As your family matures, so do your health insurance needs. From maintenance drugs and braces to insurance for your college student, it’s important to know the facts.
• Seniors: Now that your children are grown, it’s more important that you focus on your own health. Make sure you have the right coverage before and during retirement.
Many other special health insurance considerations come into play for domestic partners, single parents, military, and seniors who are raising grandchildren. Knowing your options helps you save time, money and frustration.
What is Open Enrollment?
Open enrollment refers to the period of time during which all members of your group health insurance plan have the opportunity to enroll in certain benefit programs. During an open enrollment period, insurance carriers are required to accept all applicants of the group without underwriting or evidence of insurability. Open enrollment is generally only held once a year. If you miss your company’s annual open enrollment, you likely will not be able to enroll in your employer-sponsored health insurance program until next year. Certain exceptions apply for new employees or employees with life changing events.
Make sure to check with your human resources department to see when your company’s open enrollment period begins and ends, and when your policy goes into effect, and can discuss your concerns with the selected insurance plan.
Read and Understand the Materials
There are many different types of major medical plans typically offered by employers. For help understanding the fundamental differences between preferred provider organizations (PPO), health maintenance organizations (HMO), point of service plans (POS) or indemnity plans, go to the NAIC insurance education Web site, www.InsureUonline.org and click on the life situation that most closely matches your own. The health section includes basic information about each type of program. Plan materials will detail which medical providers (physicians, hospitals, labs, pharmacies, etc.) are considered in-network and out-of-network. They will also detail how much the insurance carrier will pay under each type of plan.
Before making a choice:
• Check to see if your current physicians and area hospitals are in the plan’s network. Using network providers generally will save money on your health care.
• Check to see if spouses or dependents are covered. Some plans will cover spouses and other dependents, while other plans will not.
• Read all of the plan materials thoroughly. Doing so will tell you what your rights and responsibilities are under each plan.
• Review any pre-existing condition exclusions and prior authorization requirements in the plan materials.
• If you take prescription medications, check them against the list of approved drugs in each plan booklet.
• If any part of a plan is unclear to you, ask for help from your human resources department or the insurance carrier.
• If you are not satisfied with the answers to your questions, contact your state insurance department. Go to www.naic.org/state_web_map.htm for a link to your state insurance department’s Web site.
Compare the Cost and Coverage of the Plans Offered
In this uncertain market, it’s important to carefully evaluate your healthcare costs when making your annual enrollment decisions. While one option might have high monthly premiums and a low deductible, and another might have a low premium but more out-of-pocket expenses, it could be misleading which plan is best for you until you do the figures.
To pick the best coverage, first calculate your healthcare costs from recent years and try to estimate what your costs might be for the coming year. Don’t forget to include the cost of doctor’s visits, daily medications and any procedures you might be planning.
Next, make a list of the premiums, out-of-pocket expenses and benefits under each plan. Co-payments, deductibles and additional charges for wellness care or specialists (e.g. chiropractic care, cosmetic surgery, etc.) are examples of out-of-pocket expenses that you are responsible to pay. Remember, if you use a medical provider that is out-of-network, you will generally pay more out-of-pocket expenses. Include these fees in your calculations.
Finally, decide how much you can afford to pay. Other things to keep in mind:
• Check for any annual limits and prior authorization requirements.
• Some prescription medications have higher co-payments than others and they might vary from plan to plan. Mail-order options might be available for maintenance drugs at a lower cost to you.
• If your dependents have health insurance coverage through their employer, school or the Veteran’s Administration, compare their costs and benefits to the family plans you are considering to ensure that you choose the best plan for every member of your family. Make the same type of comparisons for any dental or vision care plans that you are offered.
Visit the NAIC's Special Section: PPACA & State Insurance Regulation for the latest news regarding healthcare reform implementation efforts.
Visit HealthCare.gov for information from the U.S. Dept. of Health & Human Services (HHS).
Resource: http://www.insureuonline.org/health_page.htm
New answer by PatientAdvocateFoundation (Organization (Verified))
1
Answer |
4 months ago
Overall many patients diagnosed with cancer find themselves underinsured or even uninsured resulting in large out of pocket medical expenses. It is important to pay bills or make payment arrangments to avoid collections that can damper your credit. However, with that being said there are some opportunities to reduce the debt owed.
If your insured you should always review and understand your plan language. Compare your explantion of benefits to your bills to verify benefits are being processed correctly. Additionally, there are multiple strategies that may be employed to help with unpaid medical bills. You may want to discuss options with your treatment facilities on ways to reduce or eliminate your out of pocket expenses:
•Apply for financial assistance through the billing office at your provider’s office or medical facility.
•You may first need to apply and be denied for Medicaid to qualify for financial assistance from the hospital.
•Co-pay relief programs may be able to cover some of your pharmaceutical co-payments. Check with each program to see what is covered. You can also contact Patient Advocate Foundation’s Co-Pay Relief Program at 1-866-512-3861 to see if you qualify for assistance with your co-payments.
•Negotiate discounts with the hospital or medical provider. Some providers will offer a discount for prompt payment of your balance.
•Drug replacement programs may be available to assist you by providing medications to your physician’s office specifically for your use. Discuss these programs with your physician.
•Contact a disease specific organization to see if there are any financial grants available to assist you. These programs vary widely and may pay for transportation or other related expenses
Communication is the key, you may find that they will honor a small payment plan if you express your needs as well.
If your insured you should always review and understand your plan language. Compare your explantion of benefits to your bills to verify benefits are being processed correctly. Additionally, there are multiple strategies that may be employed to help with unpaid medical bills. You may want to discuss options with your treatment facilities on ways to reduce or eliminate your out of pocket expenses:
•Apply for financial assistance through the billing office at your provider’s office or medical facility.
•You may first need to apply and be denied for Medicaid to qualify for financial assistance from the hospital.
•Co-pay relief programs may be able to cover some of your pharmaceutical co-payments. Check with each program to see what is covered. You can also contact Patient Advocate Foundation’s Co-Pay Relief Program at 1-866-512-3861 to see if you qualify for assistance with your co-payments.
•Negotiate discounts with the hospital or medical provider. Some providers will offer a discount for prompt payment of your balance.
•Drug replacement programs may be available to assist you by providing medications to your physician’s office specifically for your use. Discuss these programs with your physician.
•Contact a disease specific organization to see if there are any financial grants available to assist you. These programs vary widely and may pay for transportation or other related expenses
Communication is the key, you may find that they will honor a small payment plan if you express your needs as well.
1
Answer |
6 months ago
If you are requesting a medication that is off your prescription drug plan’s formulary, you will want to check with your insurance provider to determine what the process is to request an individual exception. Many health plans will give you the opportunity to request an exception based on medical necessity. For example, the medical necessity of you requesting Emend is that the alternative therapies, Zofran and Compazine, either did not work for you or that you experienced adverse reactions to them. You may want to ask your doctor to write a short letter to support your request.
New answer by PatientAdvocateFoundation (Organization (Verified)) in topic(s) Zofran, Emend, Financial, Financial Assistance, Nausea, Insurance, Health Insurance, Compazine, Chemotherapy
3
Answers |
9 months ago
At Patient Advocate Foundation, our experience with integrative and non-traditional therapies is restricted to helping patients with life-threatening diseases who have limited insurance coverage for recommended treatments or insurance does not cover them at all and thus looking for solutions to manage the debt.
However, here are be some interesting things we’ve found on this topic that might help point you in the right direction for a more complete answer.
http://nccam.nih.gov/ The National Center for Complementary and Alternative Medicine would be more aware of any national initiatives or trends with insurance companies and the adoption of these therapies as it relates to healthcare plans.
http://www.abccodes.com/downloads/AlternativeBillingCodesandYoga.pdf This is an older article but I’m guessing the industry hasn’t changed too much in this regard. This article does a nice job listing the Alternative Billing Codes as they relate to health care services given by providers (including acupuncture, massage therapy, holistic medicine, chiropractic etc).
http://www.cnn.com/2012/02/25/health/medicare-covers-yoga-heart-disease/index.html
http://nccam.nih.gov/health/providers/clinicalpractice.htm This page lists some medical focus areas where these therapies are gaining traction.
However, here are be some interesting things we’ve found on this topic that might help point you in the right direction for a more complete answer.
http://nccam.nih.gov/ The National Center for Complementary and Alternative Medicine would be more aware of any national initiatives or trends with insurance companies and the adoption of these therapies as it relates to healthcare plans.
http://www.abccodes.com/downloads/AlternativeBillingCodesandYoga.pdf This is an older article but I’m guessing the industry hasn’t changed too much in this regard. This article does a nice job listing the Alternative Billing Codes as they relate to health care services given by providers (including acupuncture, massage therapy, holistic medicine, chiropractic etc).
http://www.cnn.com/2012/02/25/health/medicare-covers-yoga-heart-disease/index.html
http://nccam.nih.gov/health/providers/clinicalpractice.htm This page lists some medical focus areas where these therapies are gaining traction.
New answer by PatientAdvocateFoundation (Organization (Verified)) in topic(s) Health Supplements, Integrative Treatments, Integrative Therapies, Insurance, Insurance Coverage, Yoga, Massage, Acupuncture
2
Answers |
9 months ago
http://finder.healthcare.gov -HealthCare.Gov has a wonderful tool to help you identify the insurance policy options available to you in your state and your age group and situation, and the site will also give you a full listing of specific insurance providers that have plans available and their contact numbers. The site will also give a brief summary of the policies so you can easily compare deductibles and plan details.
In general, for individuals no longer eligible to remain on their parent’s coverage, other options to consider include private plans like Individual Plans, Pre-Existing Condition Insurance Plans (a 6-month uninsured requirement is mandatory), Employee-sponsored Plans, adding onto a spouse’s plan if applicable, or public options if you meet the qualifications including Medicaid or a state-sponsored High Risk Pool Plan.
In general, for individuals no longer eligible to remain on their parent’s coverage, other options to consider include private plans like Individual Plans, Pre-Existing Condition Insurance Plans (a 6-month uninsured requirement is mandatory), Employee-sponsored Plans, adding onto a spouse’s plan if applicable, or public options if you meet the qualifications including Medicaid or a state-sponsored High Risk Pool Plan.
New answer by PatientAdvocateFoundation (Organization (Verified))
2
Answers |
9 months ago
This is best addressed with a medical professional however you might also reach out to any one of as number of cancer patient support discussion groups (like CancerConnect, CancerCompass) to gather the advice and experiences of other patients who have similar situations. It appears that this is a potential complication of the procedure and a quick search within these forums found a number of patient discussions revolving around the topic.
In addition, below are some articles written by one of our partners, LIVESTRONG on your question that might point you in a better direction.
http://www.livestrong.com/article/76270-mastectomy-complications/
http://www.theacpa.org/conditiondetail.aspx?id=66
http://pain.about.com/od/typesofchronicpain/a/post_op_pain.htm
In addition, below are some articles written by one of our partners, LIVESTRONG on your question that might point you in a better direction.
http://www.livestrong.com/article/76270-mastectomy-complications/
http://www.theacpa.org/conditiondetail.aspx?id=66
http://pain.about.com/od/typesofchronicpain/a/post_op_pain.htm
New answer by PatientAdvocateFoundation (Organization (Verified)) in topic(s) Breast Surgery Side Effects, Breast Surgery, Nerve Damage, Side Effects, Pain, Surgery, Surgery Side Effects, Armpit Pain
3
Answers |
9 months ago
Often medical treatment and care can be very expensive and put strain on a patient’s budget. Here are a few strategies patients can use to manage their medical debt:
Look for prompt-pay discounts: Offer the medical facility a reasonable, but specific amount of money upfront as payment in full for services. Some facilities may be willing to accept a smaller amount of money if it means they will collect at the time services are rendered.
Apply for financial assistance: Ask your provider if they have an application you can complete to receive a discount or write-off on your accounts.
Arrange an affordable payment plan: Speak with the facility’s billing department to negotiate a monthly payment plan that is feasible for your budget to prevent accounts from going to a collection agency.
Participate in Screening Programs: Ask your local Health Department about free screening programs such as the Breast and Cervical Cancer Early Detection Program. If diagnosed through these programs, patients will be referred to covered treatment options.
Manage your cost during treatmen: By asking questions and talking to your doctors, you can frequently find quality care at an equal or lower price. Walk-in retail clinics (like Minute Clinic and RediClinic), ambulatory surgery centers, outpatient services, and stand-alone imaging and blood diagnostic facilities, for example, can all be less expensive than the same services at hospitals and the doctor’s office.
Reduce future and current medical costs through a healthy lifestyle: Many patients see a reduction in their need for medications and medical care by improving their health in general through lifestyle and non-medical means. Be sure to maintain healthy habits when it comes to diet, exercise, weight, social behaviors and stress management. These can not only save dollars in terms of necessary treatment, but will also give your body the best internal tools when responding to any needed medication or medical action.
In terms of reducing expenses on pharmaceuticals, speak to your doctor to ask about lower cost and comparable medication alternatives, the use of generic brands, bulk discounts, and access to medication samples to ease the burden of cost. In addition, there may be assistance programs to aid in the cost of your prescriptions.
PHARMACY CHECKER An online resource that helps you identify, locate and compare reputable online pharmacies. www.pharmacychecker.com 718- 554-3067 Also allows patients to compare prices for medications among various pharmacy providers.
RX AID PRESCRIPTION ASSISTANCE Patient assistance programs that aid uninsured patients get their prescriptions at low or no cost. www.rxaid.us 877-610-9360
RX ASSIST A comprehensive directory of patient assistance programs run by pharmaceutical companies to provide free medications to people that cannot afford to buy their medicine. www.rxassist.org
STATE PHARMACEUTICAL ASSISTANCE PROGRAMS (SPAP) Many states have state-sponsored subsidies and discounts for seniors, disabled, uninsured and others. The National Conference of State Legislatures maintains a list of state specific prescription programs with a list of eligibility requirements. 202-624-5400 www.ncsl.org/issues-research/health/statepharmaceutical-assistance-programs-2011.aspx
DRUG ASSISTANCE CARDS /DISCOUNT PHARMACY CARDS These discount cards are offered to patients free of charge and give additional discounts on the out-of-pocket cost of medications. These cards tend to be easy to use and do not require forms to fill out or waiting periods to use. Many are offered by the pharmacy directly, including Kmart, Costco, Walgreens, Rite Aid, etc, or offered as a result of a community partnership. FamilyWize, YourRXCard and NationalDrugCard are examples of discount cards not tied to any specific pharmacy.
Patient Advocate Foundation has written a number of tip sheets and brochures relevant to this topic located. I encourage you to take a look at www.patientadvocate.org/publications, specifically:
National Uninsured Resource Directory – *(the first few chapters discuss low cost options for care and services )
Greater Understanding: Back to Basics: How to Discuss the Cost of Health Care Treatments With Your Provider
Look for prompt-pay discounts: Offer the medical facility a reasonable, but specific amount of money upfront as payment in full for services. Some facilities may be willing to accept a smaller amount of money if it means they will collect at the time services are rendered.
Apply for financial assistance: Ask your provider if they have an application you can complete to receive a discount or write-off on your accounts.
Arrange an affordable payment plan: Speak with the facility’s billing department to negotiate a monthly payment plan that is feasible for your budget to prevent accounts from going to a collection agency.
Participate in Screening Programs: Ask your local Health Department about free screening programs such as the Breast and Cervical Cancer Early Detection Program. If diagnosed through these programs, patients will be referred to covered treatment options.
Manage your cost during treatmen: By asking questions and talking to your doctors, you can frequently find quality care at an equal or lower price. Walk-in retail clinics (like Minute Clinic and RediClinic), ambulatory surgery centers, outpatient services, and stand-alone imaging and blood diagnostic facilities, for example, can all be less expensive than the same services at hospitals and the doctor’s office.
Reduce future and current medical costs through a healthy lifestyle: Many patients see a reduction in their need for medications and medical care by improving their health in general through lifestyle and non-medical means. Be sure to maintain healthy habits when it comes to diet, exercise, weight, social behaviors and stress management. These can not only save dollars in terms of necessary treatment, but will also give your body the best internal tools when responding to any needed medication or medical action.
In terms of reducing expenses on pharmaceuticals, speak to your doctor to ask about lower cost and comparable medication alternatives, the use of generic brands, bulk discounts, and access to medication samples to ease the burden of cost. In addition, there may be assistance programs to aid in the cost of your prescriptions.
PHARMACY CHECKER An online resource that helps you identify, locate and compare reputable online pharmacies. www.pharmacychecker.com 718- 554-3067 Also allows patients to compare prices for medications among various pharmacy providers.
RX AID PRESCRIPTION ASSISTANCE Patient assistance programs that aid uninsured patients get their prescriptions at low or no cost. www.rxaid.us 877-610-9360
RX ASSIST A comprehensive directory of patient assistance programs run by pharmaceutical companies to provide free medications to people that cannot afford to buy their medicine. www.rxassist.org
STATE PHARMACEUTICAL ASSISTANCE PROGRAMS (SPAP) Many states have state-sponsored subsidies and discounts for seniors, disabled, uninsured and others. The National Conference of State Legislatures maintains a list of state specific prescription programs with a list of eligibility requirements. 202-624-5400 www.ncsl.org/issues-research/health/statepharmaceutical-assistance-programs-2011.aspx
DRUG ASSISTANCE CARDS /DISCOUNT PHARMACY CARDS These discount cards are offered to patients free of charge and give additional discounts on the out-of-pocket cost of medications. These cards tend to be easy to use and do not require forms to fill out or waiting periods to use. Many are offered by the pharmacy directly, including Kmart, Costco, Walgreens, Rite Aid, etc, or offered as a result of a community partnership. FamilyWize, YourRXCard and NationalDrugCard are examples of discount cards not tied to any specific pharmacy.
Patient Advocate Foundation has written a number of tip sheets and brochures relevant to this topic located. I encourage you to take a look at www.patientadvocate.org/publications, specifically:
National Uninsured Resource Directory – *(the first few chapters discuss low cost options for care and services )
Greater Understanding: Back to Basics: How to Discuss the Cost of Health Care Treatments With Your Provider
New answer by PatientAdvocateFoundation (Organization (Verified)) in topic(s) Financial, Financial Assistance, Health Insurance, Health Providers, Personal Finance
2
Answers |
9 months ago
Your insurance company will issue what’s called an EOB- Explanation of Benefits for the services in which they have received provider claims submitted for payment relating to your care. The EOB is not a bill, however it will reference a portion of the total amount that the insurance company expects to be responsible for and a portion that you are responsible for based on your plan language. Keep in mind that these may be changed and updated as additional information is received by your insurance company from your providers. Usually, insurance companies will leave a portion of the bill as your responsibility until your full deductible is met, and only then cover in full.
You can expect to receive an actual bill from the provider’s office directly for the portion that remains on your account following the payments made by the insurance company. This is the portion you are responsible for. If you have questions about the EOB or your provider’s individual bills, contact either the customer service number on your insurance card or the billing representative from your provider’s office.
Many insurance companies these days also are offering their clients an online account area that shows updated information on all claims and care items associated with your insurance plan. This area lets you review the summary of your information all in one place and can be quite helpful.
PAF produces a brochure that briefly discusses the EOB, including a visual sample, to help. http://www.patientadvocate.org/requests/publications/GU-Explanation-Of-Benefits.pdf
You can expect to receive an actual bill from the provider’s office directly for the portion that remains on your account following the payments made by the insurance company. This is the portion you are responsible for. If you have questions about the EOB or your provider’s individual bills, contact either the customer service number on your insurance card or the billing representative from your provider’s office.
Many insurance companies these days also are offering their clients an online account area that shows updated information on all claims and care items associated with your insurance plan. This area lets you review the summary of your information all in one place and can be quite helpful.
PAF produces a brochure that briefly discusses the EOB, including a visual sample, to help. http://www.patientadvocate.org/requests/publications/GU-Explanation-Of-Benefits.pdf
New answer by PatientAdvocateFoundation (Organization (Verified)) in topic(s) Bills, Insurance, Insurance Company, Patient Bills, Medical Bills
2
Answers |
9 months ago
There are a number of websites and tools out there that will help you get an idea of what a normal charge is for a specific service associated with your healthcare. This might help you get a sense of when a charge on your statement may be the result of a coding and billing error. An example is www.healthcarebluebook.com.
Insurance companies are obligated to pay based on your specific insurance plan and the language associated with it. It is in effect a legal contract between you and the insurance company. If you have questions, concerns, appeals or disputes your contract has to discuss the method and process for which they will address your concerns.
In terms of bills, you might have more luck negotiating remaining balances with each individual medical provider, as they might be able to offer you charity care, reduced rates for prompt, cash, or upfront payments, matching negotiated rates for other insurance types, extended payment plans, etc.
Also, keep in mind that you may be able to take your negotiating skills to some of the other living expenses and items in your family budget, thus allowing you to reallocate money to your medical bills and having the same effect on your wallet.
This is also a great article that references these tips and more.http://money.howstuffworks.com/personal-finance/debt-management/10-ways-to-negotiate-medical-bill10.htm.
Insurance companies are obligated to pay based on your specific insurance plan and the language associated with it. It is in effect a legal contract between you and the insurance company. If you have questions, concerns, appeals or disputes your contract has to discuss the method and process for which they will address your concerns.
In terms of bills, you might have more luck negotiating remaining balances with each individual medical provider, as they might be able to offer you charity care, reduced rates for prompt, cash, or upfront payments, matching negotiated rates for other insurance types, extended payment plans, etc.
Also, keep in mind that you may be able to take your negotiating skills to some of the other living expenses and items in your family budget, thus allowing you to reallocate money to your medical bills and having the same effect on your wallet.
This is also a great article that references these tips and more.http://money.howstuffworks.com/personal-finance/debt-management/10-ways-to-negotiate-medical-bill10.htm.
New answer by PatientAdvocateFoundation (Organization (Verified))
1
Answer |
9 months ago
Are you disabled enough where you should consider applying for Social Security Disability (www.ssa.gov)? You would then be eligible for a monthly benefit and Medicare after 2 years and/or Medicaid if your income was low enough. This determination would be one you would have to have support from your treating doctors and show your side effects are severe enough and will exceed 12 months or more.
The economy has made finding employment a challenge for most and coupled with your need for stellar medical coverage I am sure is narrowing your search further. Typically speaking, the larger the company you work for the more balanced your medical cost tends to be, however this is not a concrete statement. We have noticed over the past several years that the cost of premiums have shifted to the "employee" themselves and benefits begain to narrow to keep the premiums affordable. We classify this population as underinsured. You may find interest in viewing our publication, The National Underinsured Reource Directory available in print form athttp://www.patientadvocate.org/pdf/1070208NUiRD.PDF. We offer some tips that you may find beneficial.
There are provisions coming with the Affordable Care Act, if you uninsured now you should look at the PCIP plans (www.pcip.gov) for coverage for medical cost. Also your state maybe one that increases their Medicaid up to 133% of Federal Povery Level. Also in 2014 exchanges will enter the market as well as affordability measures that will hopefully provide the support you need. I realize this is not immediate but if you would like to learn more you can visit www.insureUStoday.org or www.healthcare.gov.
The economy has made finding employment a challenge for most and coupled with your need for stellar medical coverage I am sure is narrowing your search further. Typically speaking, the larger the company you work for the more balanced your medical cost tends to be, however this is not a concrete statement. We have noticed over the past several years that the cost of premiums have shifted to the "employee" themselves and benefits begain to narrow to keep the premiums affordable. We classify this population as underinsured. You may find interest in viewing our publication, The National Underinsured Reource Directory available in print form athttp://www.patientadvocate.org/pdf/1070208NUiRD.PDF. We offer some tips that you may find beneficial.
There are provisions coming with the Affordable Care Act, if you uninsured now you should look at the PCIP plans (www.pcip.gov) for coverage for medical cost. Also your state maybe one that increases their Medicaid up to 133% of Federal Povery Level. Also in 2014 exchanges will enter the market as well as affordability measures that will hopefully provide the support you need. I realize this is not immediate but if you would like to learn more you can visit www.insureUStoday.org or www.healthcare.gov.
New answer by PatientAdvocateFoundation (Organization (Verified))
1
Answer |
9 months ago
If cost is a barrier to your medical care I encourage you to speak to the specialist office directly. They may offer programs internally that could waive, reduce or allow payments to ensure continuation of care while you pay what you can afford, even if just $5 a month.
If they do not offer solutions, you could seek an alternative specialist who may if that is feasible. Seek out resources that help offset the cost you cant afford such as locating a pharmacuetical co-payment program, utility assistance or food assistance for example.
Did you know that HRSA clinic (www.hrsa.gov) offer primary care to patients regardless of their insurance status based on their ability to afford? Maybe you could consider seeking primary care there if they could waive your co-pay for PCP and you could shift that cost to your specialist.
Lastly, depending on your income and asset level, supplemental insurance support could be an option through state programs such as Medicaid. I am going out on a limb but if your current insurance offers a plan with a more affordable co-pay model for a higher premium you may consider that as an option if the math shows savings in the long run.
I recommend looking at the coverage you carry now, determine if that is the best coverage you can gain access to and speak to your provider about your financial barriers.
If they do not offer solutions, you could seek an alternative specialist who may if that is feasible. Seek out resources that help offset the cost you cant afford such as locating a pharmacuetical co-payment program, utility assistance or food assistance for example.
Did you know that HRSA clinic (www.hrsa.gov) offer primary care to patients regardless of their insurance status based on their ability to afford? Maybe you could consider seeking primary care there if they could waive your co-pay for PCP and you could shift that cost to your specialist.
Lastly, depending on your income and asset level, supplemental insurance support could be an option through state programs such as Medicaid. I am going out on a limb but if your current insurance offers a plan with a more affordable co-pay model for a higher premium you may consider that as an option if the math shows savings in the long run.
I recommend looking at the coverage you carry now, determine if that is the best coverage you can gain access to and speak to your provider about your financial barriers.
New answer by PatientAdvocateFoundation (Organization (Verified))
1
Answer |
9 months ago
Often, patients make the choice to go to providers not participating in their network. If you choose to do this, it is critical to make sure that you have
"Out-of-Network" (OON) benefits under your policy. If you do not have OON benefits and you elect to receive care at an OON facility, you may not receive
ANY insurance reimbursement. If you have OON benefits, your claim will be processed using the prevailing UCR rates for the services provided. In addition, the provider may "Balance Bill" you for the difference between what the physician charges and what the insurance company pays.
When you sign up for health insurance - just like when you sign your auto or homeowner's policies- you are entering into a contract with the insurance carrier. Regardless of whom your insurance carrier is or what type of insurance you have, you are subject to the terms of your policy. It is critical for you as the patient to understand the way your policy works so you can maximize your benefits and your coverage under your plan.
Example:
OON Facility Bills Actual Charge$1 ,000.00
UCR Allowable Charge $ 400.00
60% (OON) Insurance Paid $ 240.00
Your 40% co-insurance $ 160.00
Balance Billing Choosing OON $ 600.00
Your Total Costs $ 760.00
Even if your policy has an out-of-pocket maximum, it is important to understand that ONLY your portion of the UCR amount allowed is applied towards your
maximum. In the example above, only $160.00 (your portion of the amount the insurance company deemed payable) of the $760.00 you paid is counted toward
your yearly out-of-pocket maximum. For this reason, many patients have much larger than anticipated medical bills when seeking services at an OON provider.
PAF has written a very quick read on this topic accessible at the following link:http://www.patientadvocate.org/requests/publications/GU-Understanding-Insurance-Plan.pdf
If you do not have in-network providers or facilities that are necessary to address your health condition, your referring physician should contact the insurer for an exception to seeking an out-of-network provider. This may require an appeal if a verbal request is not accepted. Evidence supporting the request will be necessary to reverse the insurers decision. In certain circumstances the insurer will pay an in-network rate however you will still be subject to the UCR amount and will have a larger out-of-pocket expense. Talk to the OON provider/facility and learn if they are willing to accept charges as full or work out a payment plan with you if it remains a concern.
PAF suggest that if you enjoy the flexibility of going to those you deem best for your illness and your current plan is limiting to seek other insurance options. It is possible you have more then on option at work for example. You should consider enrolling into the most appropriate plan that fits your medical needs during your open enrollment period (of if you have a qualifying event such a birth, divorce, marriage or loss of employment (spouse or self).
PAF cannot express the importance of understanding the current plan you carry to avoid unnecessary denial of claim and/or financial hardship due to large medical bills.
"Out-of-Network" (OON) benefits under your policy. If you do not have OON benefits and you elect to receive care at an OON facility, you may not receive
ANY insurance reimbursement. If you have OON benefits, your claim will be processed using the prevailing UCR rates for the services provided. In addition, the provider may "Balance Bill" you for the difference between what the physician charges and what the insurance company pays.
When you sign up for health insurance - just like when you sign your auto or homeowner's policies- you are entering into a contract with the insurance carrier. Regardless of whom your insurance carrier is or what type of insurance you have, you are subject to the terms of your policy. It is critical for you as the patient to understand the way your policy works so you can maximize your benefits and your coverage under your plan.
Example:
OON Facility Bills Actual Charge$1 ,000.00
UCR Allowable Charge $ 400.00
60% (OON) Insurance Paid $ 240.00
Your 40% co-insurance $ 160.00
Balance Billing Choosing OON $ 600.00
Your Total Costs $ 760.00
Even if your policy has an out-of-pocket maximum, it is important to understand that ONLY your portion of the UCR amount allowed is applied towards your
maximum. In the example above, only $160.00 (your portion of the amount the insurance company deemed payable) of the $760.00 you paid is counted toward
your yearly out-of-pocket maximum. For this reason, many patients have much larger than anticipated medical bills when seeking services at an OON provider.
PAF has written a very quick read on this topic accessible at the following link:http://www.patientadvocate.org/requests/publications/GU-Understanding-Insurance-Plan.pdf
If you do not have in-network providers or facilities that are necessary to address your health condition, your referring physician should contact the insurer for an exception to seeking an out-of-network provider. This may require an appeal if a verbal request is not accepted. Evidence supporting the request will be necessary to reverse the insurers decision. In certain circumstances the insurer will pay an in-network rate however you will still be subject to the UCR amount and will have a larger out-of-pocket expense. Talk to the OON provider/facility and learn if they are willing to accept charges as full or work out a payment plan with you if it remains a concern.
PAF suggest that if you enjoy the flexibility of going to those you deem best for your illness and your current plan is limiting to seek other insurance options. It is possible you have more then on option at work for example. You should consider enrolling into the most appropriate plan that fits your medical needs during your open enrollment period (of if you have a qualifying event such a birth, divorce, marriage or loss of employment (spouse or self).
PAF cannot express the importance of understanding the current plan you carry to avoid unnecessary denial of claim and/or financial hardship due to large medical bills.
New answer by PatientAdvocateFoundation (Organization (Verified))
1
Answer |
9 months ago
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Many of our members are learning from this information or english might not be their first language. Please use standard english and spell out all words. For example, use 'you' instead of 'u'.
The more clear and thorough your request, the more likely you will receive support.
Many of our members are learning from this information or english might not be their first language. Please use standard english and spell out all words. For example, use 'you' instead of 'u'.
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