Getting the most from your insurance

Getting the most from your insurance

Posted by AskNurseLinda on Nov 27, 2017 2:12 pm

At the point of entry to the healthcare system, I often hear people say, ‘I have insurance’ or, ‘I don’t have any insurance’.  With long term illness or trauma, one of the first things that pops into people’s minds is finances, specifically is how much is all of this medical care going to cost? Not only is the thought of testing, treatment and a long term hospital stay on their minds but ultimately, how will they pay for it all. There is no question that healthcare is an expensive circumstance.

Getting to the bottom of finances is very difficult as everyone’s situation is different. If you have no health insurance and your bank account is minimal, you will most likely be place on Medicaid which will be initiated from the time of injury or from the time of admission into the hospital. Medicaid is considered public funding. It is federally authorized but an important factor is that it is managed by each individual state. Because the management is particular to the laws that govern the state where your Medicaid is distributed, there are essentially 50 different ‘policies’. Each state has their own rules. What is the rule in one state is not in another. Benefits that are available in one state might not be covered in another.

Typically, with Medicaid as a payor, care must be provided within that particular state. I live in an area with major medical centers along the state boarder. People with Medicaid in my state can take advantage of the care provided in this major medical center. However, people with Medicaid in the next state, which can be seen just outside a window in the facility, cannot. Those people might have to travel hundreds of miles to reach a major medical center within their own state. This can separate families and communities.

Medical care provided by Medicaid cannot be less than any other care provided. That does not include therapies or equipment. Usually, it is the same physicians who provide medical treatment in private clinics as in public clinics. Differences will include things like wait times, ambiance and numbers of people to provide services. This translates into possible longer waiting times for your appointment and responses to your questions.

There are clinics that accept mostly Medicaid payment. Some clinics do not accept Medicaid payment or will only allow a percentage of Medicaid patients as indicated by law. If a clinic physician accepts Medicaid payment, they might only allow a percentage of patients receiving Medicaid in the clinic because the reimbursement for each dollar is different. Therefore, some will balance between individuals with Medicaid and individuals with other sources of payment.

Medicare, also a public program, is different. It is also a federally mandated program but it is managed by the federal government and not the state. The rules are the same no matter which state you are in. Payment may be different based on region of the US. For example, healthcare is more expensive on the east and west coast than in the middle of the country or southern states so payment is adjusted accordingly. If a physician or hospital accepts Medicare payment, then they are stipulating that they will work with Medicare. Usually, that means they will accept the payment that Medicare allows. However, there are many healthcare treatments that are not covered by Medicare so you do need a supplemental policy to cover those treatments.

Typically, Medicare is thought to be only for those over 65 years. However, if you have documentation that you have had a disability for two calendar years, you can obtain Medicare disability health insurance. You do not have to demonstrate a financial need, just having the documented disability is required. At age 65, you will automatically be enrolled into regular Medicare.

There are also public programs to insure the healthcare needs of children. These are typically sponsored by individual states. The benefits between different states varies as well as different pediatric programs within states. If you have a child enrolled in a pediatric health care program and you find a friend with a child in a different program, all within the same state, you might have different benefits. It can really become quite confusing.

Another specialty insurance is military. Enlisted, inactive and retired all have different policies which are managed by the military. They have their own rules about where you can go to receive care and what is covered.

Private insurance is the term used to describe the healthcare coverage of individuals who pay for insurance. They typically have a policy that is managed through an insurance company. Some people have private insurance through their employment for which they pay a monthly fee. This is taken out of your paycheck so you don’t really ever see the money. Your employer will send the payment through a group plan. That group is your fellow coworkers. Families can usually be added on to your plan for additional fees.

Some people pay individually for private insurance. If they have a job that does not include a healthcare benefit or if they choose to have a policy on their own, they can elect to obtain their own policy through an insurance agent or negotiate with an insurance company. If you have private insurance, you are paying a premium or a set amount to an insurance company.

When you have insurance, your policy will outline the healthcare services covered. Every policy is different. This is very important to understand. Two people can have the same insurance company but if they have different policies, their benefits will be different. You can assess price comparisons but there is almost no comparisons between individuals’ coverage because there are so many types of coverage, public and private, different insurance carries, who is underwriting your policy (it may not be the company listed) and the vast number of policies. Comparing your benefits to another person’s will typically not make much sense.

Until an emergency happens, most people do not know what their individual policy includes. People sign up for insurance and they have it, right? Not necessarily. If you have an insurance policy, you have some coverage but you need to read the policy to know what is covered and what is not. Most insurance policies cover two weeks of inpatient rehabilitation. That is the most typical plan for physical rehabilitation service. That is not nearly what is needed for something like a spinal cord injury from trauma or disease.

You can find out what is in your policy by requesting a written policy copy by contacting the number on the back of your card or by going on line and looking up your policy. Your insurance’s name is on the front of your card. When you get to that insurance site, you can look up your individual policy by the number on your card. This is true for public and private insurance.

If you find yourself in a situation where you have coverage from a public or private insurer but it is not adequate for the care you need, there are some actions that you can take. If you have a catastrophic diagnosis such as spinal cord injury or paralysis from any event, immediately ask your insurance for a case manager to be assigned to you. A case manager will be assigned from the hospital but that case manager represents the hospital, not your insurance. You need a case manager from your insurance company to assist you with payment needs. You have to phone the insurance company number on the back of your card and request a case manager. Sometimes, the insurance automatically does this with certain diagnosis but you need to ensure this is done. Ask them to contact you. Get to know this person and how to contact them. They will be your point of contact for your insurance needs.

Sometimes, the case manager can move benefits to assist you in getting the services you require. For example, many individuals need more time in rehabilitation hospitals. The case manager can --sometimes-- move nursing home benefits into your rehab hospital stay. Once this is done, the option of long term nursing care is out so you have to be careful about what you request and how your policy is managed. Sometimes the case manager is not allowed to make these special arrangements but it does not hurt to ask.

If there is a treatment or therapy that is not covered by your payor, you can ask your healthcare professional write a letter of medical necessity on your behalf. This is a special request that asks your insurer to provide something for you that is not covered in your policy. Depending on the situation, it may or may not be covered. Be sure you have your healthcare professional write the letter of medical necessity as they know the terminology and justification that will best help your case. Sometimes people are successful with these requests but not always. Just because a letter is sent does not mean you will get what you want or need. Work with your healthcare professional as the letter of acceptance or denial will be sent to you, the policy holder, not the healthcare professional. There is a method of appeal which is based on a tight timeframe so you need to provide the information to your healthcare professional as soon as possible.

Insurance is helpful in managing your finances whether it is public or private. Each has advantages. People with public insurance often wish they had private but this is not the answer. Many private insurance cover just the bare minimum, in which case for some diagnosis like spinal cord injury public can work out better that a minimal private policy. Learn how to work within your system asking for a case manager and learning to negotiate with letters of medical necessity. It is a challenge but can be surmounted.  Nurse Linda

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