Tips to Follow When Your Health Insurance Doesn't Want To Pay

Many of us feel blessed because we are able to pay/qualify for Individual or Group Health Insurance.  

The story changes dramatically when a major health situation occurs and we find out the hard way that our policy (and sometimes our health company) is not as comprehensive as we had believed.

There are tips that you can follow (before or after something happens) that can help you determine whether your health insurance company is not covering a procedure because it is genuinely NOT covered by your policy or whether they're not covering it in the hope that you pay for it yourself. 

The first thing you should do is request a copy of your health insurance application. Why? because your answers in that application determine whether the insurance company can claim you concealed health information from them (and therefore your policy is VOID) or not. 

If they do void your policy it is a perfectly legal and retroactive move. In some situations all they have to do is refund your premium payments, others don't even get that back.  This is not what you want to hear when you're facing bypass surgery, dialisis or cancer diagnosis and you need your treatment to stay alive!

Second. Learn what your covered benefits are and their limits (if any).  A mostly unknown clause from a lot of policies is your out of pocket maximum. Typically this refers to services that qualify for co-insurance.  After your reach this (usually yearly) "Maximum" the insurance company is to pay 100% of your expenses that year. 

Find out and follow their internal Appeal process and document every call/letter regarding the uncovered bill(s). 

Have your doctor give you a letter outlining why this procedure is "medically necessary" AND the historical success rate of this procedure. Then, get a 2nd and even 3rd opinion (with letters) before submitting your appeal. 

Do not get wrapped in unreasonable time frames, if you need this procedure approved call/write/ email. Stay on top of the situation and have it go through their "expedited" processes.  If they're denying the claim, continue their internal appeal process or hire a Patient Advocate. 

Finally. Discuss your case with a reputable (and INDEPENDENT) Patient Advocate. Keep in mind that the "in house" Patient Advocate many hospitals/insurance companies have on staff may feel pressured to do what's best for the company.

 

20/20 John Staussel Reports on "Medicare Greed"

I had to comment on this "teaser" article I just read on ABC news regarding Medicare use by "ritzy" senior citizens.

If the article is true and the seniors they interviewed do live in these $350K to $500K a year "communities", why are they still using medicare? 

John Staussel is doing an In-depth report this Friday on the subject. The seniors say they do get payments from medicare for what's allowed... 

The question then becomes, do they need Medicare? should there be a "top income" limit after retirement to who gets government benefits that they clearly don't need? 

I can't wait for the show :) here's the link to the ABC site:

http://abcnews.go.com/2020/Stossel/story?id=7522306&page=1

Medicare Part A/B And Medigap (or Supplemental Insurance)

My parents are going to be eligible for Medicare in the next two years and I could not believe all the choices that they must make! or the sometimes ridiculous time frames. 

I'm helping them go through the different options and so I wanted to briefly discuss them today :)

Medicare Part A: 

It is equivalent to a "Major Medical/Indemnity" policy. It helps cover (Key words! since it is not covered 100%) your inpatient care in hospitals, critical access hospitals and skilled nursing facilities. It also covers hospice care and some home health care. It's free of charge for those that have worked more than 10 yrs in "medicare covered employment" (check with the Social Security administration for your individual status).

Medicare Part B: 

It's the one that helps cover your doctors’ services, outpatient hospital care, and some other medical services that Medicare Part A doesn’t cover, such as some of the services of physical and occupational therapists, and some home health care. Medicare Part B helps pay for these covered services and supplies when they are medically necessary.

IT IS NOT FREE or automatic. You must apply for it before you're eligible or it could be delayed up to 3 months!! 

The monthly Premium for Medicare Part B in 2009 is $96.40 

By the way... if you chose not to enroll in Medicare Part B when you first become eligible there's a 10%  penalty added to your Premium fee FOR LIFE for every 12 month period that you wait. 

Neither A or B covers prescription medication. That's a separate plan with a separate premium. 

Medigap (or Supplemental coverage) would help you pay for what Medicare A/B doesn't cover.... but it is also a separate Plan (Plans A through L) with an additional premium. 

Believe it or not the medicare website was most helpful with the original "information search". Here it is: 

http://www.medicare.gov/MedicareEligibility/home.asp?version=default&browser=Safari|2|Windows+Vista&language=English

However, I'm continuing the search since I would feel better hearing what other people that are actually using the particular plan have to say about it. 

A great deal of attention is given to costs... we're putting more emphasis on plan performance/ reputation of the companies. 

Cost Recap: Monthly Premium for Medicare Part B    $96.40 (plus any penalties)

      Monthly Premium for Medigap                    ???? (****)

      Monthly Premium for Prescription Meds   ???? (****)

**** depends on what plan you choose

Health Insurance Basics

While surfing the web I found this great Forum with some simple yet correct basic Health Insurance terms. 

They discuss the two different types of health Insurance (Indemnity and Managed Care) and other Health insurance options as well as some tips about buying affordable coverage.

It is very detailed for a one page "run through", so if you're looking for basic information this is the page to go:

http://www.ampminsure.org/health-insurance.html

The Myth of Saving Money on your Insurance Premiums

I advise families every week regarding websites advertising how much they can "save you" on Insurance Premiums (whether life/health/home/auto). 

In my opinion they are misleading and is all a myth.  

The two ways to save actual money on your premiums is to lower your risk by being healthy, having a good background check (including good credit and low or none traffic violations/accidents)... and of course taking advantage of any discount programs offered by some companies for "bundling" their products. 

Otherwise, it won't happen since most reputable Insurance companies (A and B rated) use about the same information as a guide to decide what premium you as an individual will be charged. 

The "quotes" you receive over the phone, online OR even face to face with your favorite agent are not going to vary "wildly" (if they do there's a red flag for you) and are ALL pending the ACTUAL information that comes after you've put in an application and the company is able to do a background/credit check and or a physical. 

The way I explain it to my clients is this: "the application is just that... an application.... NOTHING MORE..." 

Based on your answers in the application a seasoned agent should know whether there's reason for concern or not even before submitting it. 

Once the application is "turned in" and they take a look at your background/credit records (and/or physical if required for Life/Health policies) one of three things can happen: they can accept you at the price quoted, they can give you a different (usually higher) offer OR in the worse case scenario they can decline to issue a policy at all.

Each company has a set amount of "risk" that they're willing to take with each new policy. Remember, the Insurance Companies are "betting" that you will not need this policy. You are betting that you will... 

For those clients that have questionable backgrounds (whether that's health/credit concerns) there are reputable companies that would care of "higher risk" individuals for a higher fee.

Remember that applying to a lot of different insurance companies "willy-nilly" would hurt your "background check"... much like it would hurt your credit report to apply to many loans/credit cards...  

In the next blog I'll discuss how to get "good quotes" so you avoid getting "surprised" when your actual policy arrives and what makes a "good Insurance company".

What is PMI? and How can I stop Paying for it!

PMI stands for "Private Mortgage Insurance". However, don't be fooled by its name. It is entirely for the benefit of your lender so that THE LENDER may recover their money in case the client defaults and there is still a balance after the foreclosure sale. 

In most cases a lender requires PMI from clients that did not have 20% to put as a "down payment" on their home and/or from clients that are considered "high risk" for any other reason. 

The Lender is required by law to drop PMI after your loan payments have reached the equivalent of the 20% downpayment or your house value has grown. In the past it was the clients responsibility to notify the lender when they reached that point and overpaying PMI was not unheard of. In 1999 a new Federal law made that responsibility mutual. 

However, the law has many "exceptions" and the lenders will always err on what's best for them. therefore, I advise my clients to keep an eye on their requirements because it could save them $400 or more per year. 

Without getting into too much "industry lingo", the bottom line is that you're supposed to stop paying for it at some point. 

Just using your payments (and whether or not you "overpay" your loan) as a guide it could take you 10-15 yrs to get to the 20% "threshold", but even with this housing market slump there are some areas that are still gaining some value at a low percentage anually. You can reach that 20% much faster than the Lender is willing to admit with a combinacion of your payments and market value gain. 

Check out this site from the Federal Trade Commission that discusses PMI in more Detail:

http://www.ftc.gov/bcp/edu/pubs/consumer/alerts/alt072.shtm