Any time the Insurance changes we go in to freak out mode. Having a child with multiple medical conditions and trying to manage it all is a super daunting task if you are not extra organized, like me. I’m getting better over the years but it has been one long road mixed with a few tears. This topic is one AIM would love to give our readers a few tips about especially for those things we’ve found out the hard way. Our goal here is to help you a smidge before things get too crazy.
I’ll be honest, the days of having excellent insurance coverage are far and few between now. If you are fortunate to have decent insurance in the first place, you often find it’s more fluff and fine print than coverage or “benefits”. With the amount taken out of a paycheck monthly, then co-pays, deductibles, out of pockets and co insurance who can really afford insurance these days when it comes time to actually use it? It often becomes a game of balance and really getting in to the fine print of the plan itself to actually capitalize on the “benefits” to your family.
Below are a few things highlighted that we have found helpful either by mistake, necessity or when navigating through a momentary crisis.
CERTIFICATE OF COVERAGE: Get your “Certificate of Coverage” free of charge BEFORE you sign up for your latest plan if possible. If already in the middle of the plan, you can request one simply by calling your employer HR dept or even the insurance company itself. Either can issue this to you. I’ve been given the COC easily through email but it can also be mailed in paper form as well. Sometimes you can even find it online if you have a third party type plan and access with a user name and password. Just ask. Promise it will be worth the two hours of time it takes for you to read through it and discover all things excluded or available to you that even the customer service people fail to know.
The fine details and conditions (benefits, exclusions, obligations, co-pays, pre-certifications, appeal process, and preferred healthcare provider networks) will be listed in this 200+ page pdf but I promise you, you’ll learn a thing or two and be in a better position to decide if the plan offered is something your family can live with or not. So important when literally every penny counts these days.
DEDUCTIBLES: While we all understand what a deductible is, have you thought to ask how many people have to meet that crazy # before you’re covered at a certain percentage? An example of this is below:
$4500 Family deductible- How many plan members have to meet their deductibles in order to satisfy that minimum? *Sometimes that # can be 3 out of 5.
$1500 Individual deductible- What in your plan contributes to your deductible? *Co-pays typically do not. Ask how you meet it? And make sure you ask what does not apply?
Question 1: After meeting the individual deductible, what percentage am I covered?
Question 2: After meeting family deductible, what percentage am I covered?
Question 3: Does my pharmacy cost or copay contribute to the medical deductible?
Question 4: What percent do we pay until my out of pocket is met?
Write this all down if you are asking and highlight if you’re reading. Those #’s add up quickly and will help you determine what plan you can accept or not. That’s IF you have a choice. Who knew it could get so complicated? I remember a time when we just paid our monthly fee, deductible and wahlah =100% covered as it should be. Gone. Insurance companies and employers have gotten smart. Many no longer have a high deductible or 100% coverage type plan. When you have a medical complicated kid, that 10% can be a second mortgage. Trust us.
FSA vs HSA: Because we just don’t have enough acronyms when it comes to our community right? These two (Flexible Spending Account and Health Savings Account) can actually be quite helpful if available. Here’s a good article explaining the differences and how to decide what may be the best option: http://www.forbes.com/sites/christinalamontagne/2015/07/13/my-employer-offers-both-hsa-and-fsa-whats-the-difference-and-which-should-i-use/
OPEN ENROLLMENT: Pay attention to this time period. Usually the month before your medical health plan is going to come into renewal you’ll be warned. The dates will be highlighted for when your old plan will expire and new plan begins. You should receive a warning via email and a hard copy in the mail. Pay attention to see what changes have been made to your current plan. Sometimes that plan will no longer be available and you’ll need to start looking into details for a new one. *In our case the plan was almost the same except our monthly fee went up and additional exclusions were added. So pay close attention or call your HR department for more specific details about the plans provided. They are there to help you.
PHARMACY: Since when does insurance dictate health care you ask? Last year it did for us. Apparently, at any point in time, your insurance can stop paying for a medication (even if you’ve been taking it for years) and have the pharmacist give you the good news when you are 7 lanes away from the window thinking you heard it wrong. “That will be um, $678.10 for 30 day supply Mrs. Smith, ok? ” Um, WHAT?!?! SAY WHAT?!? Can you say immediate heart attack?
Did you know the formulary (drug list) is subject to change”? Ya, neither did I. So let’s all thank the lord above my car was in park because things were about to get real. Luckily my pharmacist calmly explained this to me and offered to help in any way they could. We ended up having to appeal and won but it took 6 weeks and my child didn’t receive the appropriate medication for the time period. He actually had complications from their “suggested cheaper replacement drug”. Unacceptable I know, but there was literally nothing I could do except breathe and follow the appeal process. We won in the end but not a fan. Below are things I learned the hard way.
FORMULARY = Insurance approved drug list- ask for it and or look it up for your plan.
STEP THERAPY CRITERIA= sometimes the insurance company (not a doctor) determines there’s a cheaper, “effective” drug kind of similar to the one you take. They will suggest a few to your pharmacist and you may have to get a new prescription after talking it over with your specialist and then see how that works out for all. If you’re not cool with that, time to appeal and with urgency. Key word= URGENT. Put that in bold at the top and bottom of every page.
Basically, insurance is attempting to change your medication (you know the one you’ve been on for 5 years) so that it benefits them, not you the consumer. If you “try it” in the pinch be ready to appeal with your physician either writing letters with research to support your request or even peer to peer review so that they can “talk it out” MD to MD. Meanwhile, your urgency is not their urgency so understand this may take a few months.
Things we learned here and asks you can use:
-Ask, don’t yell at the customer service person for appropriate wording to write your appeal.
-Ask what you are actually appealing? That person you’re talking to (write their name down by the way and use it in your letter) will tell you specifics. Write them all down and begin to construct your letter that way.
-Ask for an URGENT Fax # you can send your appeal to?
-Ask if it’s better for YOU to send the appeal or will it expedite if the SPECIALIST does this from his office? Where should the letter come from?
*ASK, if someone can you give you back the 5 hours of your life this took to get your Insurance degree?
BALANCE BILLING: Say what? I wanted to cry, a lot when this happened to us last year. My middle son had an emergency and needed to go to the IN NETWORK ER. He was immediately brought into the back and a full workup ensued. After passing through front desk personnel, nurses, technicians and two medical doctors we were admitted, treated and 3 days later discharged. Only to have to return the same day for the same condition and stay another 3 nights but that’s another blog.
A couple weeks later, we got the bill.
Apparently everything was peachy but a little hiccup. One of the doctors that came in the room to treat my son (that I did not choose) was not “in network” with our insurance. The hospital, the nurses, the technicians were, but not him. I was slapped with a $1800 bill and told to pay up. Not understanding how this could be, I called my insurance. They informed me they could only apply out of network benefits and to contact that hospital. So, I called the hospital and they told me sorry but they couldn’t do anything and to contact my insurance. Seriously? Not a good way to start my day and so I decided to search around and came upon this government site.
The Texas Department of Insurance: http://www.tdi.texas.gov/consumer/complfrm.html
Once I familiarized myself with the information provided above and using the correct lingo “I’ll be calling and writing the Texas Department of Insurance to file a formal complaint” I then called back the hospital and we talked it out with those words exactly. They dropped the balance charge and allowed the payment from the insurance company as paid in full. Apparently, they can do that when they like. Crisis averted but hours of my life wasted on the phone. So here are a few tips and things to work on if this unfortunately happens to you.
1. Take notes of every conversation, names and anything discussed. Dates and times included.
2.Again, don’t freak out and scream- I’ve done that and it doesn’t work. Talk calmly but be assertive.
3.Ask to be removed from possible “collections” while you work on gathering information.
4.Request an itemized bill for your review before making any payment. You’d be surprised how many questionable things can be “added”.
5.Negotiate with the hospital if you’re in a position to do so. We have been given discounts if paid in full.
6.Truly write the complain letter and tell the hospital you’ll be sending it if you can’t get anywhere. You may be surprised how quickly things change. I can’t think of one hospital that likes formal complaints against them on record. Just sayin.
7.Keep a sign you can wear in your purse or car that says “WE HAVE xxx INSURANCE. IF YOUR NOT CONTRACTED DO NOT TOUCH ME”.
There’s so much more to write but Insurance already takes up way too much of all our time. Hopefully there is something here you can use. And please let us know if you’ve learned anything out there yourself that would be helpful to our community.