Insurance / Medicare Tips

Health insurance is a key issue facing NTM patients, but understanding or choosing your health insurance is not easy. Here are some tips to make it a little easier:

Review Your Health Insurance Plan

Health insurance plans change from year to year. Each year carefully review and be familiar with sections of your health insurance that are important to your health conditions. Sections on home healthcare and prescription drug coverage might be particularly important to you, so it may help to highlight those. Don’t assume they’ll stay the same from year to year; review them annually. If you are unclear about any part of your plan, call your insurance company to get answers to your questions.

If you have a choice between different health insurance plans, review each one carefully; compare costs such as co-pays and prescription drug coverage, as well as deductibles and premiums. Pay particular attention to any exclusions from coverage.

Not all health insurance plans are created equal. Some will be better than others for you. Insurance differs both in how much you have to pay and how easy it is to get the services you need. Although few insurance plans will pay all the costs of your health care, some will cover more costs than others.

Choosing the health insurance plan with the lowest premium may not be in your best interest. Sometimes these plans pay much less for prescription drugs and health care, which can cost you more money in the end.

The Six Cs of Insurance

Coverage: Do the services covered match the services you need? Will the insurance provide necessary drugs and equipment? Are there any exclusions?

Co-pays: Few health insurance plans cover every expense. Out-of-pocket expenses, called co-pays and deductibles, are what you pay. Make sure you know what these are. You also go to doctors based on their specific expertise in treating pulmonary NTM disease. Make sure they are in your health insurance provider’s network, and if they are not, what part of the costs are and are not covered. Also take a good look at the prescription drug co-pay. Some insurance companies have you pay for the drug first and then fill out the paperwork before they will reimburse you for the drug. Other companies require you to pay a percentage of the cost, and it will cover the rest without you having to lay out the money in advance. Have a list of each medication you will take, noting which are brand name and which are prescription, and find out which drugs are covered by your insurance and what your co-pay is.

Claim Payment: Find out what you have to do before your insurance will pay the medical bill.

Some companies do not pay the bill until you fill out their paperwork. Others ask you pay the bill first and fill out paperwork in order to be reimbursed.

Conditions That Affect Payment:

Be aware of certain provisions, such as needing to call the insurance company for prior authorization or approval before getting certain prescription drugs, tests, or before being admitted to the hospital.

Find out if the health insurance company has a set timeframe to submit a claim or paperwork after services have been provided. Some insurance will not pay for services if a claim has not been filed within a certain time period, such as 90 days or six months. Check the insurance coverage for pre-existing conditions. Does your insurance plan consider NTM lung disease a pre-existing condition?

Caps on Benefits: Many health insurance plans place dollar limits on the amount to be paid

for medical equipment, physical therapy, or prescription drugs. However, lifetime caps on coverage will, under the new federal health care laws, no longer be allowed as of 2014.

Cost of Insurance Premiums:

Insurance with lower premiums often have higher co-pays and deductibles, meaning you could end up paying much more out of your own pocket in the long run. For example, insurance with a lower premium may only pay 50 percent of your prescription drugs. This can be cost-prohibitive for NTM patients since treatments usually involve drugs that are less common and far more expensive than standard antibiotic therapies for more common ailments. A better option might be to pay a slightly higher monthly premium for insurance that pays 80 to 100 percent of your prescription drug costs and/or one that requires a smaller co-pay.

Health Insurance Coverage Laws

Certain federal and state laws affect health insurance coverage. The Consolidated Omnibus Budget Reconciliation Act (COBRA) can help you keep your group health insurance. All employers with 20 or more employees are required to offer COBRA, which allows you to extend your group health insurance when you change jobs, if you go through a divorce, when your child turns 18 years old, or for other life events.

The coverage can last up to three years depending on why you extend your coverage. You will have to pay all the premiums, but this can help you avoid a gap in insurance coverage (remember that if more than 63 days have passed without coverage, your group insurance can refuse to pay for any pre-existing condition) until you get a new job or health insurance. You can request a Continuation of Coverage form from your health insurance company.

The Health Insurance Portability and Accountability Act (HIPAA) also helps people who have group health insurance. Under HIPAA, you can get credit for the amount of time you had insurance under another health insurance plan. This is called creditable coverage.

Taking Action

You will probably have some medical bills your insurance will not pay at first (“denial of coverage”). When this happens, you can appeal the decision. Call your insurance company and find out why there was a denial of coverage, and ask what you need to do to appeal the decision.

Keeping your medical bills organized will help you manage the process of dealing with health insurance companies. Match up insurance statements that show payment and match them to the medical bills, and copy and date anything you send to your insurance company. Review your medical bills and write down your clinic visits, prescription drugs, and the result of your treatments.

Keep notes when you talk with your insurance company. Write down the date, time, first and last name of the person you spoke to, what you talked about and what you agreed to. Ask the person you spoke with to send you, by e-mail or U.S. mail, what you agreed upon in writing. Maintaining these records will come in handy if you have to appeal a denial of coverage.

Before you appeal decisions, consider asking your insurance company for a case manager to assist you. A case manager is a specific person at the insurance company assigned as your representative. Many people find that having a case manager makes it considerably easier to navigate the complexities of dealing with health insurance companies, and they can also take on some of the work of following up on your claims.

Useful Links

For step-by-step guidance to challenging health plan decisions: http://www.kff.org/consumerguide/upload/7350ConsumerGuidev4_080805.pdf

To learn whether your state has a law providing an independent review of denied benefits, see the charts created by the National Conference of State Legislatures, http://www.ncsl.org/programs/health/hmolaws.htm


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