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Help! I'm Underinsured...




Help! I'm Underinsured... has been written in response to the many concerns that have been identified by PAF patients. Many Americans, even the fully insured, are still unable to pay the out of pocket expenses, i.e. co-payments, deductibles, co-insurance, etc. that insured patients face. Often these patients are underinsured. Financial challenges as a result of a chronic, life threatening or debilitating illness can be quite overwhelming. It is critical that you read and understand your insurance plan language. This is what will dictate how your insurance company pays for the services you receive while undergoing treatment for your medical condition. While some indigent or charity programs require no insurance coverage to participate, there may be other resources that an underinsured patient can access. This publication strives to provide information that will assist those struggling financially. It is our sincerest hope that Help! I’m Underinsured……..will provide you with the necessary tools to both educate and assist you in your time of need.




Unpaid Medical Bills

There are multiple strategies that may be employed to help with unpaid medical bills. You may want to discuss options with your treatment facilities on ways to reduce or eliminate your out of pocket expenses:

  • Apply for financial assistance through the billing office at your provider’s office or medical facility.
  • You may first need to apply and be denied for Medicaid to qualify for financial assistance from the hospital.
  • Co-pay relief programs may be able to cover some of your pharmaceutical co-payments. Check with each program to see what is covered. You can also contact Patient Advocate Foundation’s Co-Pay Relief Program at 1-866-512-3861 to see if you qualify for assistance with your co-payments.
  • Negotiate discounts with the hospital or medical provider. Some providers will offer a discount for prompt payment of your balance.
  • Drug replacement programs may be available to assist you by providing medications to your physician’s office specifically for your use. Discuss these programs with your physician.
  • Contact a disease specific organization to see if there are any financial grants available to assist you. These programs vary widely and may pay for transportation or other related expenses.





Clinical Trials

Another option you may want to consider for treatment is a clinical trial. Clinical trials are research studies designed to test new methods of prevention, screening, diagnosis or treatment of a disease. A clinical trial may provide you with an opportunity to access new therapies while having some or all of the related costs covered by the trial.

Check with your physician to see if you may qualify for a clinical trial. You will also want to check with your insurance company to verify that your policy covers participation in a clinical trial. Some trials absorb most or all of the expenses associated with treatment, and can be a cost effective way to access quality care. For a listing of trials you may want to contact:

National Institute of Health (NIH):
focuses on all trials regardless of disease.
Call 1-800-411-1222 or
visit http://clinicaltrials.gov.

National Cancer Institute (NCI)
focuses on cancer related trials.
Call 1-888-624-1937 or
visit http://www.cancer.gov.






Insurance Policy Issues

You need to make sure you have a complete copy of your insurance plan. Read your policy manual and be aware of any specific policy requirements. If your policy has a preferred provider network or if there is a preauthorization requirement you need to be aware of those before beginning treatment. Even a fully insured person may be faced with policy limits for a calendar year. Understanding your policy benefits is your best defense. A majority of insurance plans have a maximum out of pocket expense per calendar year. This amount does not include your co-pays, deductibles and premiums. Once you have met your maximum out of pocket expense your insurance company often covers all of the remaining charges per their contract. However, Usual and Customary charges will apply if you receive care outside your provider network. This often leads patients to have large out of pocket expenses they may not have been anticipated. For more information refer to our publication Usual, Customary and Reasonable Charges (UCR) Defined.

Another issue you may be facing is a pre-existing condition rider or a waiting period. This pre-existing condition waiting period will place limits on the benefit amount or disease for which insurance coverage is provided. The length of time for this waiting period will be listed in the policy and is usually 12-18 months. To avoid any pre-existing issues and to ensure protection under the Health Insurance Portability and Accountability Act (HIPAA) there cannot be a lapse in insurance coverage of more than 63 days. Once a member is no longer covered under a plan they will be issued a certificate of creditable coverage to demonstrate previous insurance coverage to your new insurer. This coverage only applies to group insurance plans. To learn more about your protections under HIPAA visit http://www.dol.gov.

Depending on your situation, there may be programs available to assist you with funding for out of pocket expenses. Your physician’s office may be able to advise you what resources are available. You may be able to access either community programs or financial assistance programs at your treatment facility.





Medicaid

Medicaid is a federally-funded, state-run program that provides medical assistance for individuals and families with limited income and resources that meet certain covered guidelines. There are various Medicaid programs available even for those with insurance. Since Medicaid eligibility requirements vary from state to state, a person who is eligible for Medicaid in one state may not be eligible in another state and the covered services may differ also. You need to check with your local department of Social Services to see if you qualify for any of their programs. Also, check with your local Medicaid office to find out if your state offers a HIPP (Health Insurance Premium Payment) program. The HIPP Program can pay your health insurance premium as opposed to providing you with Medicaid. Seniors with limited income may qualify for Medicaid in addition to Medicare.






For patients facing a critical diagnosis, understanding all available options can seen overwhelming. This information is provided as a brief overview about issues that are often complex. For further information, either call the Patient Advocate Foundation at 1-800-532-5274 or visit our website www.patientadvocate.org.




References

ACS Hope Lodge
http://www.cancer.org

Blue Cross Blue Shield Association
http://www.bcbs.com/glossary.html

Cancer Prevention and Control (CDC)
http://www.cdc.gov/cancer/nbccedp/

Division of Facilities Compliance and Recovery (DFCR)
http://www.hrsa.gov/osp/dfcr/

The Georgetown University Health Policy Institute, "A Consumer Guide for Getting and Keeping Health Insurance,"
http://www.healthinsuranceinfo.net

Henry J. Kaiser Family Foundation
http://kff.org/uninsured/index.cfm

Insure.com
http://www.insure.com

Insure Kids Now;
http://www.insurekidsnow.gov

Investorwords.com
http://www.investorwords.com/791/catastrophic_coverage.html

The Leukemia and Lymphoma Society teleconference
http://www.leukemia-lymphoma.org

National Association of Health Underwriters
http://www.nahu.org/consumer/HRPGuide.htm

National Association of Hospital Hospitality Houses, Inc.
http://www.nahhh.org/index.php

National Institute of Health (NIH)
http://www.nih.gov

National Patient Air Transport HELPLINE
http://www.npath.org

Needy Meds;
http://needymeds.com

NOLO
http://www.nolo.com

Partnership for Prescription Assistance (PPA)
http://www.helpingpatients.org

Patient Advocate Foundation Co-Pay Relief Program
http://www.copays.org

U.S. Department of Health and Human Services, "Free Hospital Care, Nursing Home care and care provided in other types of health facilities under the Hill-Burton Program,"
http://www.hrsa.gov/osp/dfcr/

U.S. Department of Labor Employee Benefits Security Administration, "An Employee's Guide to Health Benefits Under COBRA-The Consolidated Omnibus Budget Reconciliation Act of 1986" (Revised September 2004)
http://dol.gov

U.S. Department of Labor Employee Benefit Security Administration, "Health Coverage Portability-Health Insurance Portability and Accountability Act of 1996 (HIPAA)" (October 2004)
http://dol.gov