Family
caregivers are concerned not only with the worry if their loved one is getting
the best medical care, but also the financial burden associated with it. According to Families USA, 60% of all
bankruptcies are due to medical debt.
Family caregivers need to know how they can maximize their insurance to
lower their costs.
Don’t take “NO” for
an answer
Families
have a right to appeal claims that are denied by insurance. There are different ways to do this based on
the type of plan. All plans come with
handbooks explaining this process, whether it’s a public or private plan. Only 1/3 of families appeal a claim when it’s
denied, but half of the time it’s turned around on the first try. For private plans, it may be something as
simple as sending the “explanation of benefits” on why it was denied, along
with any missing information requested, and a doctor’s note of medical
necessity. Parents should keep copies of
everything, send it certified/return receipt, and follow-up if needed since
there may be a deadline on the appeal.
It may be a good idea to send a copy to your state insurance
commissioner (see resources); even if the plan is “self-funded/self-insured”
and is exempt from state regulation due to ERISA (Employee Retirement Income
Security Act), these are the same plans that go for the Medicaid contracts in
your state and they don’t want to look bad.
Again, there may be both internal and external appeals, and families
need to check the process in their plan handbook.
New Benefits under
the Affordable Care Act
Besides
not being able to drop plans due to illness or deny due to “preexisting
condition”, there are now no lifetime caps on benefits and children can stay on
a parent’s plan until age 26. It should
be easier for families to get mental health care due to the new federal parity
law which requires equal treatment for mental and physical health as well as
autism coverage under one of the essential health benefits of “behavioral
health.” Qualified health plans in the
Marketplace also have to cover children’s dental and vision care. Prevention and wellness care is at no charge.
What is Coordination
of Benefits?
Families
of children with special needs may have more than one insurance plan. Children with disabilities may have private
plans as well as public plans like Medicaid or Medicare. The private plan usually pays first, and the
public plan pays the rest. But families
still may have to remind doctors and pharmacies that they need to bill both so
families don’t end up paying out-of-pocket.
Other helpful tips:
Ø If a family has
Medicaid as the second insurance but the provider doesn’t take Medicaid, the
provider can call the HMO and ask what the process is to bill Medicaid “out-of-network”
as the secondary.
Ø If a family has
Medicare and the doctor doesn’t take Medicare, the provider can send in his/her
Medicare opt-out letter with the bill to the private insurance. Families can also file Medicare claims in
this manner.
There
is a factsheet on how to get the different types of insurance and how to
coordinate benefits at
http://www.spanadvocacy.org/content/coordination-benefits-having-more-one-insurance-plan
or Spanish at http://www.spanadvocacy.org/content/coordinacion-de-beneficios-tener-mas-de-un-plan-de-seguro.
Family
caregivers need to get the most out their insurance which will help ease any
financial strain on families. Below are
resources that can assist if families need more help.
Resources
The
Arc
Families
USA
Family
Voices/Family-to-Family Health Information Centers
SHIP Counselors (Medicare)
State Departments of Insurance-National Association of Insurance Commissioners
Title V of the Maternal/Child Health Bureau
Remain Hopeful,
Lauren
Lauren Agoratus is a parent/advocate who works for the Statewide Parent Advocacy Network and serves as the NJ Coordinator for Family Voices (www.spanadvocacy.org), a national network that works to “keep families at the center of children’s healthcare” at www.familyvoices.org or FB www.facebook.com/pages/Family-Voices-Inc-National/137783182902269. She also serves as NJ representative supporting caregivers across the lifespan for the Caregiver Action Network (formerly National Family Caregivers Association) in a volunteer capacity at http://caregiveraction.org/ or FB www.facebook.com/CaregiverActionNetwork
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