medical health insurance

Who’s On First?

Following up on our blog from a few weeks ago — having “double the benefits” with two working spouses and two health plans — we’re adding Medicare to the mix.

Sample Scenario —

Husband: takes retirement, is 65 or older (and/or is disabled), and has Medicare as his primary health insurance coverage.

Wife: continues working, has employer based health care benefits for her and her husband.

He goes to the doctor and assumes Medicare will cover the visit and any treatments or tests. But it ain’t necessarily so! And that’s why he MUST let his health-care providers know about his wife’s employer-based plan.

In a nutshell . . .

As a non-active employee (an individual who is retired, on COBRA or Long Term Disability), the husband would typically be covered by Medicare as his primary insurance. However, as a dependent on his wife’s insurance, the size of her employer’s group will determine primacy: if there are fewer than 20 employees, Medicare pays first; more than 20, her health insurance pays first and Medicare pays second.

The rules for coordination can be complex. Keep your health plan administrators informed of changes or other coverage. Make sure your doctors know about the dual coverage and present both cards at the time of your visit.

Questions? That’s our specialty — finding answers, determining solutions. So, call if you need us. You can also contact the Medicare Coordination of Benefits Contractor at 1-800-999-1118.

Meanwhile, just remember, the answer to Who’s on First? can be a tricky one!

Choosing the Right Health Plan- Benefits by Design -

Continuing last week’s discussion, Choosing the Right Health Plan, let’s look at how the actual Benefit Design can — and should — shape your purchasing decision.

When we say benefit design, we’re simply acknowledging that medical insurance plans come in various shapes and sizes; you need to pick one that fits you and your family.

What’s in a Name?

Everything. The name itself often represents the type of product, reflects plan rules or highlights a unique element. Example: HDHP stands for “high deductible health plan!”

HMO, PCP, Gatekeeper — these names are associated with benefit designs from health plans versus insurance companies. They generally require a referral from a primary care physician before you see a specialist. Does that work for you? Are you willing to engage with a primary care physician as part of your health care team? Open Access, on the other hand, typically means you don’t need a referral from a primary care physician to see a specialist.

Points of Service

Before purchasing a health plan, make sure you understand how it’s designed in terms of service. For instance, will you be covered — to some degree, at least — if you see a non-participating doctor?

Warning: if you call a doctor’s office to see if they participate with your insurance and you get this response, “We accept all insurance” DO NOT think it means they participate with your plan. It simply means they’re willing to accept a check from anyone. Ask more questions.

Need physical therapy? Want to see a chiropractor? Make sure these services are covered and if there are limits on visits. It’s not unusual to see benefit designs with limited coverage for these services.

There’s a lot to consider when choosing a heath plan. And the wrong decision can be costly. Check with your state’s Department of Insurance website for a list of all licensed insurance companies and health plans doing business in your state. See what’s available. And when in doubt, consult an expert for advice.

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Choosing the Right Health Plan

With the recently passed health care reform legislation, millions of Americans will find themselves having to “purchase” health care coverage. Whether you’re getting coverage for the first time, evaluating Medicare options, shopping for individual insurance, or choosing a plan from options offered by your employer, the process can be complicated and confusing. Start by evaluating the following:

Your Budget

Even if you qualify for a subsidy, determine how much you can pay for health care on an annual basis. Questions to ask yourself:

Who will be on the plan? Just you? You and a spouse? What about children? The new bill allows for adult children up to age 26 to stay on a parent’s plan. This decision affects premium rates.
Which works better for you: a lower monthly premium with an upfront deductible or a higher premium with no upfront deductible?
What about co-pays? If you go to the doctor frequently, you might want a plan with lower co-pays, a higher monthly premium and little, to no, upfront deductible.
Think in terms of surgery and preventative care (physicals, colonoscopy, etc). Check the plan for out-of-pocket (meaning your dollars) costs for these services. Many benefit plans include preventative services. Explore this carefully as it could have significant impact when you need care.

The Network
Once you’ve determined budget issues, consider the network. Make a list of all the doctors and health care providers you and your covered family members have seen in the last 12 months. If you currently have coverage, register for and use the plan’s website to review your claims history. Using this information, assess your needs by answering these questions:

Do see certain primary care or specialty doctors on a regular basis?
Do you prefer a particular hospital?
Do you want to be able to obtain second opinions outside of your local area? If so, you might want a health plan that includes some level of coverage for non participating doctors.

When evaluating your needs, be sure to include health care professionals such as physical therapists, chiropractors or optometrists.

Next week Health Champion will explain how to evaluate benefit designs. If you have any questions — or issues you’d like covered — please leave a comment and we’ll address your concerns in an upcoming blog.

Read Your Plan Documents

How was I to know that my health plan didn’t cover this?…

With over 25 years each working within the health care system, you can only imagine how many times we at Health Champion have heard this question. Whether receiving a unique or experimental treatment, seeking care from a state-of-the art facility, or simply seeing a doctor who happens to be outside of your health plan’s network, you can easily find yourself in a frustrating and expensive situation if you don’t know what your health plan covers.

Health insurance is a valuable benefit especially in today’s times. Unfortunately, too many people really don’t know much about their plan and don’t seek to learn about their coverage until they are in the midst of a crisis.

Fortunately, there are numerous resources available to health plan members. Health plans go to great length to provide information to their members. Benefit summaries, membership agreements and other coverage documents are typically available in hard copy or on-line. Members can contact their health plan’s customer service line or refer to the plan web site to learn how to access this information.

Health plan members should review their coverage and make certain they understand how their health plan works. And most importantly, Health Champion strongly encourages members to review their health plan before seeking care and whenever they have a question about whether a service is covered.

Prior to seeking treatment ask yourself, “Am I 100% certain these services are covered by my health plan?” If not, reach for your membership documents or call customer service! Many employer plan years begin in January. Now is a great time to review your health coverage!

Caring For Your Mental Health

If you — or someone you love — is struggling with mental illness, you already know the health care system is broken. At its best: disjointed and inadequate. At its worst: inaccessible to folks desperate for an appropriate diagnosis and treatment. The majority of individuals needing help fall between the cracks of long established requirements around age, income and insurance coverage.

Will Health Care Reform change all that?

In reality, there are very few provisions directly addressing mental health in the legislation recently approved by the House and the Senate.

But don’t be discouraged. There’s actually some good news. According to the American Psychiatric Association, the approved legislation extends mental health parity to individual and group policies purchased through government-sponsored health exchanges.

In basic terms, this legislation . . .

Mandates that these policies provide equal coverage for mental and medical conditions; they cannot differentiate between the two in establishing coverage limits. This is major! The original (2008) mental health parity legislation applied only to large employer plans in the private marketplace.
Bans companies from denying health insurance based on pre-existing conditions, including mental health diagnoses.
Eliminates lifetime limits on coverage.
Prohibits insurers from varying premiums based on an individual’s health status, one of the most frustrating issues faced by people with mental health diagnoses.

These provisions alone have the potential to extend health insurance coverage, including mental health, to approximately 30 million currently uninsured individuals and families.

Now that’s a good start. But it’s not perfect.

Like anything destined to change the way we think and do business, health care reform requires continued insight, input and evaluation. As health care advocates, we support this process and champion the inclusion of enriched mental health benefits as part of our re-designed system.

What do you think? We invite you to post comments; join the conversation on this critical issue.

C is for COBRA — Critical Coverage During Hard Times

If you’re on Cobra, coverage information is as critical to your wallet as it is to your well-being. But, like most folks, you probably have so much on your plate these days, you’re missing important updates.

Last week, for instance, we received a call from one of our small business clients. Their office manager thought she read that COBRA received another extension. But she wasn’t sure. Was it true?

The answer is YES. On December 22, 2009, President Obama extended federal subsidy of COBRA for an additional six months.

Some Background:

The first federal subsidy, signed into law earlier in 2009 as part of the economic stimulus package, helped fund COBRA premiums for employees who were laid off between September 1 and December 31, 2008 — “involuntarily terminated” was the eligibility language. Eligible employees paid 35% of the COBRA premium, while employers paid the remaining 65% and received a tax credit.

The premium reduction was also made available for group health insurance, which is required by State law to provide comparable continuation coverage (such as some “mini-COBRA” laws).

Good News. The Recent Extension . . .

Adds two months to the COBRA premium reduction eligibility period, which now ends February 28, 2010.

Increases the maximum period for receiving the subsidy, adding an additional six months, taking it from nine to fifteen months.
Allows for an extension of the typical grace period for those individuals whose subsidy ended before this extension was passed and couldn’t afford COBRA without it. You must pay your portion of the COBRA premium at the reduced rate by the new grace period. (Contact your carrier or speak to your Human Resource Department for specific information.)

Important Considerations. . .

If you paid 100% of the COBRA premium in December, after your subsidy expired, you are eligible for a credit or reimbursement of the overpayment. Contact your plan administrator for further information.
Be on the lookout for “notice” requirements that must be provided by plan administrators to all individuals who have qualifying events from September 1, 2008 through February 28, 2010.

Information changes rapidly and it comes at us from all sides. That’s why it’s helpful to have a reliable resource, like this Blog. We’ll work hard to give you critical, updated news and helpful links. For additional COBRA information, including helpful questions and answers, check out the Department of Labor’s website at:

http://www.dol.gov/ebsa/faqs/faq-cobra-premiumreductionEE.html

The Test Gets Authorized

“Why won’t my insurance cover a CT Scan of my heart that the doctor says I need.”

That was the call we received recently from a woman who was confused, upset, and uncertain about getting the care she needed. She’d had questionable results from both her stress test and her cardiologist recommended that she follow up with a CT scan ( to be exact, her doc wanted a CT scan of her coronary arteries, affectionately known as code 0146T).

But her insurance company refused to authorize this critical test.

Why? Was there anything we could do to help?

We went right to work and here’s what we discovered:

The cardiologist’s office followed protocol by calling the woman’s health plan and submitting the required information. However, what was submitted didn’t meet her insurance guidelines.
We obtained a copy of the company’s guidelines for radiology, and then compared the information sent by the doctor.
We then interviewed the woman and discovered she’d neglected to mention certain symptoms to her doctor.
We discussed those symptoms with the doctor’s office; they updated the information, sent it off for insurance review, and the test was authorized.

Lessons learned…

Always ask why. If you need a test/procedure and your health plan won’t authorize it, ask for clarification. You’re entitled to a copy of the guidelines used to make the decision.
Don’t assume that your doctor’s office will engage with the health plan on your behalf. Stay on top of the situation.
Review the information and symptoms you’ve shared with your doctor and see if there’s more that might be helpful.
If you’re having trouble getting answers, enlist help. Don’t just settle for “no.”
Realize that by enlisting a private advocate, you save time and money and get results.

Health Champion Blog

"In Your Corner"