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RSSGetting the Most Out of Your Health Insurance
by Kimberly Calder, MPS
If you or a loved one is living with cancer, you know how important your health insurance is to your health and financial stability. Since virtually all health plans are shifting more of the costs onto their enrollees, it is wise to make sure you are getting the best value out of your health plan. Understanding the terminology and rules of your plan and maximizing your benefits and appeal rights are critical to optimizing your coverage. Ask yourself these questions.
How well do you understand your
health plan?
Many people are understandably
confused by the terminology
of health insurance. Make sure you understand
the terms and concepts written
into your health plan manual or member
handbook. Online glossaries are
available at HealthInsurance.org and
FamiliesUSA.org. Never hesitate to
request clarification from your coverage
provider. You may also want to
clarify the different entities involved in
the administration of your health plan,
which could include a third party administrator,
a pharmaceutical benefits
manager, a case manager, and an external
review agent.
How well do you understand your
benefits?
Your plan manual will include
a list of covered benefits. It may include
a separate list of excluded benefits as
well. Understand that these are general
guidelines and that other restrictions may
apply. For example, your plan may cover
home care, but that doesn’t mean you
won’t be limited to a certain number of
visits or hours of home care, or to certain
home care providers.
When verifying a specific benefit with your health plan, ask for details in writing and be prepared to involve the physician who prescribed the drug or service to support his or her prescription more formally with your health plan. Health plans routinely require prior approval of many of the tests, procedures, medications, and specialized services people with cancer need. Your healthcare team is accustomed to these requests and will advocate for your needs when their specific recommendation is critical.
Many people are understandably confused by the terminology of health insurance.
Kimberly Calder
Your prescription drug coverage can be limited by the plan’s formulary (the specific list of drugs the plan will cover), quantity limits, specific doses, and brands. If your drug benefits are tiered, the higher the tier of your drug, the more you will have to pay out of pocket. Try to get as much detail about these types of restrictions on your prescription drug benefits as possible, and work with your doctor to identify any less costly alternatives that are likely to work well for you.
Are you in the best health plan for
your needs?
If you are lucky enough
to be covered by an employer or union
that offers a choice of plans, take advantage
of your annual enrollment period to
carefully compare your options. With
the help of your healthcare team, do your
best to anticipate the types and amount
of health services you may need in the
coming year. Then prepare yourself for
hard choices between limited benefits
in one area, such as a high deductible or
annual cap on prescription drugs, in exchange
for a lower premium or richer
coverage for something else. Take your
time to research all your options, which
may include coordinating your primary
source of health insurance with another
source of coverage if one is available
to you. Some out-of-pocket costs are
inevitable, but using a flexible spending
account, allowable tax deductions, and
other good financial planning can minimize
their impact.
Medicare beneficiaries have such a wide variety of choices to make about organizing their benefits that consulting with a Medicare expert is recommended. In addition to Medicare itself (1-800- MEDICARE, medicare.gov), several nonprofit groups are available for consultation at no cost. You may also want to check with your State Health Insurance Program (SHIP). In addition to assisting with making decisions about your basic Medicare benefits, good counselors can alert beneficiaries to cost-saving possibilities, as well as provide guidance with Medicare prescription drug plans and supplemental (Medigap) plans.
Would you know how to file an
effective appeal if you needed to?
Everyone has the
right to at least
two levels of appeal,
but many
people assume
they can’t win
or they conduct
them ineffectively.
Before filing an
appeal, check
your plan manual
first since there is
no point in appealing a denial for something
that is clearly excluded from your
coverage. Effective appeals are short,
business-like letters that include your
doctor’s best argument (including citations
from relevant studies) for the
medical necessity of a prescribed treatment.
Finally, follow up and be polite.
♦ ♦ ♦ ♦ ♦
Kimberly Calder is the director of Insurance Initiatives for the National Multiple Sclerosis Society.
This article was originally published in Coping® with Cancer magazine, May/June 2009.
