Insurance Plans Basics
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- Dominic Stewart Shelton
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2 Insurance Plans Basics Eliza Manriquez, RN Certified Case Manager JA Mom
3 Hello Bonjour Ni Hao Hola Guten Tag Ciao Konichiwa
4 Basic Insurance Terminology Pieces of the Pie Deductible - the amount YOU must pay before the insurance company starts to pay. Out of Pocket Maximum - the total amount you need to pay for the year * Co-insurance the percentage YOU pay for covered items AFTER completing the deductible Copay Set amount you pay for specific care (e.g. doctor visit copay or medication copay) In Network Doctors, facilities and other providers who participate with your insurance plan Out of Network Doctors, facilities and other providers who do NOT have a contract with your plan and can balance bill YOU for anything the insurance company does not pay. Plan Year Dates your policy is in effect. Does not always correspond to calendar year. Prior Authorization those services or medications which require approval from the insurance company before receipt. Step Therapy Usually applies to medications where a lower cost (often generic) medication must be tried before using a higher cost medication.
5 Know Your Plan You have a right to a copy of your entire insurance policy. The policy includes EVERYTHING which is covered or excluded, in other words what the insurance company will or will not pay for. The policy also includes any specific requirements to receive care (e.g. prior authorization, step therapy, limited visits, etc.) The policy tells you what responsibility YOU have (deductible, OOP Max, copays, coinsurance, etc.)
6 Where Can I Get a Copy of My Plan? Online - many insurance companies provide online access to your plan, although some only provide basic details. Customer Service - your insurance company should give you a number to call for questions. Call it and request that a complete copy of your policy be sent to you. Human Resources - the HR department at your work will have the complete insurance policy. Request a copy.
7 What they say (example) Rehabilitation and Habilitative Services Outpatient Therapy Short-term outpatient rehabilitation services for: Physical therapy. Occupational therapy. Speech therapy. Pulmonary rehabilitation therapy. Cardiac rehabilitation therapy. For all rehabilitation services, a licensed therapy provider, under the direction of a Physician, must perform the services. Please note that we will pay Benefits for speech therapy only when the speech impediment or speech dysfunction results from Injury, stroke, cancer, autism spectrum disorders or a Congenital Anomaly or is needed following the placement of a cochlear implant. Benefits can be denied or shortened for Covered Persons who are not progressing in goal-directed rehabilitation services or if rehabilitation goals have previously been met. The following services are not covered: Outpatient rehabilitation services, Spinal Treatment or supplies including, but not limited to spinal manipulations by a chiropractor or other doctor, for the treatment of a condition which ceases to be therapeutic treatment and is instead administered to maintain a level of functioning or to prevent a medical problem from occurring or reoccurring. Speech therapy to treat stuttering, stammering, or other articulation disorders. 80% of eligible expenses after satisfying $2,600 deductible. Any combination of Network and Non-Network Benefits is limited as follows: 60 visits for any combination of physical therapy and occupational therapy, per person per calendar year. 90 visits for speech therapy per person per calendar year 20 visits of pulmonary rehabilitation therapy per calendar year. 36 visits of cardiac rehabilitation therapy per calendar year. 50% of eligible expenses after satisfying $3,700 deductible. Any combination of Network and Non-Network Benefits is limited as follows: 60 visits for any combination of physical therapy and occupational therapy, per person per calendar year. 90 visits for speech therapy per person per calendar year 20 visits of pulmonary rehabilitation therapy per calendar year. 36 visits of cardiac rehabilitation therapy per calendar year. 90 visits for speech therapy per person per calendar year 20 visits of pulmonary rehabilitation therapy per calendar year. 36 visits of cardiac rehabilitation therapy per calendar year.
8 What They Mean (example) You are covered for certain therapy services. There is no coverage for others. You must complete your deductible, then the plan will pay at 80% until you reach your OOP Max. After reaching your OOP Max, plan will pay 100%. You have a certain number of visits allowed per plan year for each type therapy.
9 Keep Track of Your Claims Staying on top of your claims is vital A good filing system, spreadsheet or other method will keep you organized Review claims regularly and as soon as possible after service is completed Notify insurance if something is wrong or you don t understand how it was processed
10 Insurance spreadsheet Date Provider Amount Deductible remaining OOPMax remaining 1/1/2015 START PLAN YEAR /2/2015 Dr. A /5/2015 Pharmacy /20/2015 hospital (infusion) /30/2015 PT /5/2015 Pharmacy /22/2015 Dr. Z
11 Insurance Companies are Full of Humans
12 Mistakes Happen Report any errors in claim processing. Speak with a supervisor. File an Appeal Keep DETAILED notes of the dates and times you contacted insurance, with whom you spoke, what you said and they said. If you still think there is an error, call again... And again... And again.
13 Be the Squeaky Wheel!
14 Resources Case Manager - can help navigate insurance process, assist in finding appropriate care, explain medical terminology, guide treatment Social Worker can help find resources to assist with treatment Prescription Assistance Programs can help with cost of medication copays Charitable organizations can provide support and sometimes financial assistance for specific diseases or conditions
15 More Resources - Arthritis Foundation guide to prescription co-pay support and financial assistance for specific arthritis drugs. -financial assistance to families so their children can start or continue critical medical treatments, regardless of disease type or condition - charitable organization that provides medical grants to help children gain access to health-related services not covered, or not fully covered, by their parents commercial health insurance plan - financial assistance programs to children and adults diagnosed with critical or chronic illnesses. - The Partnership for Prescription Assistance (PPA) will help you navigate the many free and reduced price drug programs panfoundation.org - the Patient Access Network Foundation is a 501(c)(3) non-profit organization that provides eligible patients with co-payment assistance through 41 disease-specific funds that give them access to the treatments they need
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PLAN FEATURES Deductible (per calendar year) Out-of-Pocket Maximum (per calendar year) None Individual None Family $2,000 Individual $4,000 Family Member cost sharing for certain services may not apply
Coverage Period: Coverage for: Plans: This is only a summary of your GatorCare pharmacy benefits. Coinsurance: you your Dependent Copayment: you
This is only a summary of your GatorCare pharmacy benefits. If you would like detail about your coverage and costs, you can get the complete terms in the policy or plan document at gatorcare.magellanrx.com/member
Pre-exposure Prophylaxis for HIV Prevention
Mountain West AIDS Education and Training Center Pre-exposure Prophylaxis for HIV Prevention Cost and Access: Tips from the Field Joanne Stekler, MD MPH October 12, 2017 This presentation is intended for
a guide to Reimbursement of Intermittent Catheters Know your options M2116N 04.08
a guide to Reimbursement of Intermittent Catheters 1 Know your options Coloplast Corp. Minneapolis, MN 55411 1.800.533.0464 usmedweb@coloplast.com www.us.coloplast.com is a registered trademark of Coloplast