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Patient Advocate Foundation
help@patientadvocate.org
Phone: (800) 532-5274
Fax: (757) 873-8999
Self-Help Action Items

Self-Help Action Items

Having these suggestions handy will be helpful when speaking to your providers or insurance representatives. Each pull-down tab below includes a check list and questions to ask.

Capped Benefit (Annual/Lifetime/Specific Cap)

Capped benefit limits such as annual, lifetime or specific benefit are caps on how much the plan will pay.

  1. Review policy to determine benefit cap limitation period
  2. Seek coverage options through personal or alternatively sponsored plans for better coverage (i.e. employer or spousal coverage)
  3. Apply for state Medicaid or county medical assistance where available
  4. Inquire through treating hospital, facility or provider about assistance programs
  5. Explore discount drug options with large retailers, supermarkets, or pharmacy chains
  6. Discuss drug replacement programs with the physician

What are my benefits?

What are my annual caps?

Do I have specific service caps (i.e. Physical Therapy, Home Health Care, Pharmaceuticals)? What are they?

What is my lifetime maximum amount?

Inability to Afford Out-Of-Pocket Cost

Inability to afford out-of-pocket cost include co-payments, co-insurance and deductibles.

  1. Seek coverage options through personal or alternatively sponsored plans for better coverage (i.e. employer or spousal coverage)
  2. Apply for state Medicaid or county medical assistance where available
  3. Inquire about assistance programs offering payment arrangements or self-pay discounts, partial or full charity care
  4. Maximize insurance benefits by following the plan language
  5. Discuss drug replacement programs with the physician
  6. Explore discount drug options with large retailers, supermarkets, or pharmacy chains
  7. Seek financial assistance through state, national or disease specific co-pay assistance programs

What is my financial responsibility?

What is my premium and the frequency in which it must be paid (i.e. per month, quarter, biannually)?

What are my co-payments?

What is my co-insurance?

What are my deductibles?

What is my annual out-of-pocket maximum?

Non-Covered Service/Insurance Denial

A non-covered service or insurance denial can result from a pre-existing, benefit exclusion or pre-authorization issue such as a previous medical advice or treatment before the effective date of the health insurance plan.

  1. Review specific reason for denial
  2. Seek coverage options through personal or alternatively sponsored plans for better coverage (i.e. employer or spousal coverage)
  3. Maximize insurance benefits by following the plan language
  4. Explore discount drug options with large retailers, supermarkets, or pharmacy chains
  5. Discuss drug replacement programs with the physician

What type of service is needed?

Why was the service denied?

What is the cost?

When does my pre-existing waiting period end?

Is pre-authorization required?

Out-Of-Network Issue

Out-of-Network (OON) issues can occur when a member uses a hospital, physician or other providers that do not have a contract with the insurance plan. The member will be subject to balance billing, the difference between what the provider charges and the insurance pays. Some plans do not offer out-of-network benefits leaving the member financially responsible for all claims.

  1. Maximize insurance benefots by following the plan language
  2. Determine if an out-of-network service is NOT available within network
  3. Explore alternative plans during open enrollment period
  4. Inquire through treating hospital, facility or provider about assistance programs
  5. Explore discount drug options with large retailers, supermarkets, or pharmacy chains
  6. Utilize resourcesthat provide "cost calculator" for common procedures

What is my financial responsbility?

What is my OON deductible?

What is my OON cost share (the percent you are responsible for)?

Are there above Usual, Customary, and Reasonable Charges (UCR)?

What is my annual out-of-pocket maximum?

Catastrophic Plan - Limited Benefit Plan

Catastrophic only plans or limited benefit plans are insurance policies that provides limited benefits often with low monthly premiums and caps on out-of-pocket expenses.

  1. Seek coverage options through personal or alternatively sponsored plans for better coverage
  2. Apply for state Medicaid or county medical assistance where available
  3. Inquire through treating hospital, facility or provider about assistance programs
  4. Maximize insurance benefits by following the plan language
  5. Inquire about assistance programs offering self-pay discount partial or full charity care
  6. Explore discount drug options with large retailers, supermarkets, or pharmacy chains
  7. Discuss drug replacement programs with the physician
  8. Use free clinics for routine and primary care
  9. Utilize state and federal programs for free pap and mammograms, breast and cervical cancer screening, and diagnostic services

What are my benefits?

What is my deductibile?

What is my co-insurance?

When will I meet my annual out-of-pocket maximum, when plan pays 100% of all covered charges?

What is my lifetime maximum benefit, also known as caps on coverage?

Pharmacy/Medication Related Issue

Pharmacy/medication related issues such as generic only, off-formulary, specialty/high tier, benefit limits, no pharmacy coverage.

  1. For Medicare beneficiaries, apply for low-income subsidy
  2. For Medicare beneficiaries, apply for available state drug assistance programs
  3. Apply for full or partial Medicaid
  4. Secure available employer sponsored plans to act as secondary coverage or replacement as primary coverage
  5. Apply for national or disease specific co-pay assistance programs
  6. Explore mail order options for larger cost savings
  7. Consider generic equivalent medications with doctor approval
  8. Explore discount drug options with large retailers, supermarkets, or pharmacy chains
  9. Apply for free or reduced drug programs available through pharmaceutical companies

What are my benefits?

What is my deuctible?

Do I have tier and corresponding co-pay or co-insurance?

Is there a mail order cost savings?

What is not covered?

Is pre-authorization required?

COBRA Related Issues

COBRA issues can range from your inability to afford premiums to loss of coverage or simply exhausting benefits.

  1. Inquire into premium assistance programs to help offset the cost (i.e. federal, state, disease specific)
  2. Inquire with your local Medicaid office about availability of premium assistance
  3. Explore alternative insurance
  4. Financial programs to help offset the additional premium cost

What is my premium?

What is my due date?

What is the address to send payment to?

What is the start time and the term date?