They are words we hope we’ll never hear: “your health insurance claim is denied.” It happens, though – millions of times each year. Sometimes a denial is legitimate – the treatment truly is not covered by the insurance policy. But at other times the claim was denied in error.
A recent study by the Kaiser Family Foundation revealed that, when faced with a denied health claim, fewer than one percent of consumers appeal.* The study did not explore why consumers don’t appeal. It is likely that sometimes they don’t appeal because they are so busy dealing with all their health problems and don’t have the energy to deal with it. In addition, I can imagine that consumers may be intimidated by the complexity of the insurance world; I can also imagine some people may not even realize that appealing is an option.
When I read how few people appeal, I was concerned. I want consumers to know they can appeal, and that they should appeal if they believe a medical treatment should have been covered by their policy. NOTE: insurance companies generally allow a specific window of time in which to appeal – probably 2-4 months – so try to deal with it fairly speedily.
Knowing you have the right to appeal is the first step. Contacting the insurance company to request a written statement explaining the reason for denial is step two.
From there, options vary. You may be able to enlist support from your medical provider to justify the medical necessity or clear up any coding errors. Beyond that, ask the insurance company to outline its appeal process, and follow it carefully, keeping copies of all correspondence. If your appeal is denied by the company, ask about an external appeal process — some types of plans include provisions for external review.
If you are not satisfied with how your appeal is handled, consider a complaint through the Iowa Insurance Division. ISU Extension’s Iowa Concern Hotline (800-447-1985) is another resource when you don’t know what steps to take next; their staff attorney provides legal education and may be able to help you identify additional options.
*Note: the data used in the KFF study was limited to plans offered through the healthcare.gov Marketplace; it is possible that appeals rates might be different for other plans, including employer-sponsored plans.
On Super Bowl Sunday in my area it was so foggy you could not see your hand in front of your face. While many were preoccupied with football (or the commercials), there were others that were taking advantage of weather that easily conceals illegal activities.
On Monday morning, my colleague found that the family’s storage unit, located a few blocks from their home, had been broken into. In total, there were 4 or 5 units that had been broken into, plus it was obvious that unsuccessful attempts were made on several other units. An examination of the storage units that withstood the break-in attempts made it clear that the quality of the padlock is what made the difference in the safety of the contents. My friend was lucky because only tools and equipment were stolen — not the classic car they also had stored in the unit.
This is a common problem among rural properties. Farmers often have buildings that they only spend time in during the spring, summer and fall months. Thieves will frequently enter these building and take a few small items. Their intent is to see if you notice that the small things are missing AND to take inventory of larger, more expensive items stored in the building. They may also leave something leaned or stacked in a certain way that would topple or need to be moved if someone entered the building. These tactics inform the thief whether someone does visit this building. After several weeks, if the building still appears un-visited, they will come back and help themselves to the big-ticket items. A lot of farmers use trail cameras, (cameras used by hunters to study the activity of animals in the area) to monitor building sites or even their homestead.
With all the new and fairly inexpensive security equipment on the market – doorbells with cameras, spotlights with built-in cameras and small camera units – it is no surprise that the police are having an easier time catching thieves. It is also interesting to see the number of police and neighborhood postings on Facebook asking for help in identifying thieves that are caught on home security systems. As for my friend, it was suggested by local police to consider using a trail camera to keep an eye on their storage unit and, of course, to purchase a better lock.
In much of Iowa, our recent winter weeks have held lots of days suitable only for staying indoors. We’ve canceled or postponed many plans, and some of our dogs have missed lots of walks because some days were just too cold or windy.
So what can we do with those snow days? I have an idea!
No, it’s not binge-watching your favorite shows or movies, nor does it involve baking. You don’t need ME to suggest those!
My idea is less recreational, but much more valuable in the long term: go through your files!
Cleaning and organizing files is a task we tend to procrastinate. But in an emergency, and even in many non-emergency situations, we sure would like to turn to our files and immediately put our hands on the document(s) we need. When need arises, we’ll be glad we invested some time in getting organized.
Here’s the good news: it’s a task that can be broken up into small doses.
- If you already have a filing system, you can just go through one or two files a day, to pull out old materials that are no longer needed, and make sure the most current information is in front.
- If you do not have a filing system in place, start with a small stack of papers from wherever you’ve been storing them. Create file folders or envelopes for each category of papers you run across. For example, if the first paper you come to is about your car insurance, then create a car insurance file. Perhaps the next item will be college transcript – if so, create an education file.
Well-organized files have three characteristics: 1) they are clearly labeled; 2) the newest and most important information is in front; and 3) out-of-date and unimportant documents are removed. Determining what is important can be a challenge. Some tips for starters:
- Insurance – keep the most recent summary of coverage (declarations page). In addition, keep the full policy booklet if you have one, and any updates you receive about coverage details.
- Mutual fund accounts – keep your quarterly statements until the year-end statement arrives; that should include all activity for the year, so you can discard the quarterly statements. Keep all year-end statements, with the most recent in front. Keep the most recent prospectus. There is no need to keep annual reports.
- Monthly bills – once you get the next statement showing that your payment was received, you can safely discard the previous statement, unless you need it for tax purposes.
- Warranties and purchase records for warrantied items – keep as long as you own the item. Keep the purchase information longer if the item affects your taxes.
- Taxes – after six years, they can be discarded.
Personally, my biggest filing problem is old folders with labels that have fallen off – I need to go through and re-label files. Which filing task most needs your attention?
Making a decision about health insurance coverage is not easy. Most of us rely on our employer to wade through the details of policy coverage and negotiation of rates. We gladly accept what is offered, choosing between 2-3 options that personalize the coverage. HR sends a letter or hosts a meeting for questions and answers. If we don’t do anything, the policy we have continues into the new year.
It’s not quite as easy when you are purchasing insurance on your own: some parts of Medicare, the Marketplace, and plans offered from private insurance agencies can be more confusing. The options for coverage have experienced a period of volatility. Assistance with enrollment varies. Here is an overview of the open enrollment time frame, who can help you sort through the options, and major changes to be aware of in 2019:
Medicare: Open enrollment for Medicare Advantage and Prescription Drug coverage (Medicare D) began on October 15th and closes on December 7th. SHIIP volunteers are excellent resources to help sort coverage and find plans that will meet your needs. Medicare is also providing assistance through an online education program, Medicare Plan Finder. Advantage plans are increasing in numbers and are being heavily marketed this season. Individuals enrolled in supplemental coverage (Medigap) and prescription drug (Medicare D) plans should open and read any notices they received in the past 30-60 days. Your coverage may have changed.
Marketplace Coverage: Open enrollment began on November 1 and closes on December 15th. Iowans may call 1-800-318-2596 or visit healthcare.gov for information. Independent insurance agents may be able to assist. If you received assistance last year, try contacting the agency that sponsored the service. Medica and Wellmark will be offering ACA-compliant individual health insurance plans to Iowans statewide for plan year 2019. If you currently have coverage through the exchange and do not choose a plan for 2019 by the end of open enrollment, you will be re-enrolled into the same plan offered by Medica. Reminder: if you want to use Premium Tax Credits to help cover the cost of your insurance, you must purchase it in the marketplace.
Private Plan Coverage: Enrollment is not limited to a set period of time for most policies. The Iowa Insurance Division provides a listing of licensed agents. New this year for individuals who do not qualify for premium tax credits are association benefits plans.
Children’s’ Health insurance Plans (known in Iowa as HAWK-I): Enrollment is not limited to a set period of time. Contact the Department of Human Services for applications and program details.
Medicaid: Enrollment is not limited to a set period of time. Individuals may qualify based on income or specific health issues. Contact the Department of Human Services for applications and program details.
Iowa State University Extension and Outreach has available education programs that can help with understanding choices and coverage. Contact your local extension office to request delivery for your community.
The wife of a dear friend has lived in a care center for about 10 years now. I frequently cross paths with him and can see how much he misses her. I called him, excited to hear the details, when I saw on Facebook that she had moved back home. He explained that as her condition deteriorated over time, the cost of care in the nursing home had increased…so much so that they could no longer afford for her to live there.
That sounds like bad news, but it is truly turning into good news for them. You see, my friend has now retired from farming, and he can provide some of the care in their home. They have found it much more cost effective to hire a nurse to come at scheduled times to provide care and guidance for my friend, who wants only the best for his wife and is eager and able to be her caregiver. This solution has brought much joy to their home, as they are together again under the same roof.
As we plan for the future in retirement, we often think about three stages: early retirement when we do more traveling or activities that cost more…the middle years which cost less, when we are still healthy but do less because our goals have been met…and the later years when our health care cost rise. For my friend, the thought of bringing his wife home was not part of the original plan. Once he retired from farming and was more available to provide care, it made sense. It is important to make a plan but to also revisit that plan and see if it is still the best solution even after it has been implemented. Plans can always be revised.
The Finances of Caregiving is a series of five 2-hour workshops to expand your understanding of possible solutions for providing care for a loved one and help families plan together for the care receiver’s care. Understanding your choices means knowing your current situation. This program guides you through finding and collecting that information; it also provides information about communication strategies and options for care. To find a location of a program being offered near you, check out www.extension.iastate.edu/humansciences/finances-caregiving
Prescription drug costs are getting a lot of media attention these days, sometimes leaving consumers unsure who to trust. One question raised by news coverage is the question of how much we should trust our insurance plans to get us the best deal. According to a recent study, nearly one-fourth of all prescription purchases would be less costly to consumers if they paid cash rather than having their insurance cover the purchase. In other words, their co-payments were more than the actual cash cost of the medication.
The report said it is common for this overpayment to occur with generics. A news report gave an example where the difference was dramatic — a $285 copay compared to a $40 cash price. It seems unthinkable, yet it happens!
Consumers have told stories about this problem for years, but the recent paper from the Schaeffer Health Policy Center at USC was the first known systematic study, so only now are we learning how widespread the problem was; the study, which examined 2013 data, indicated that 23% of all prescriptions involved this kind of overpayment. A few states (not yet Iowa) have passed laws against this practice, but anecdotal reports suggest that it is still widespread.
I’m reminded of the classic consumer advice: “Let the buyer beware;” when in doubt, we need to check things out carefully, gathering information on our own rather than trusting an outsider’s guidance. In fact, the report mentioned that pharmacists’ contracts often include gag rules which prevent them from telling patients about this, unless they ask.
SO – next time I fill a prescription, I’m going to ask: how much would this cost if I just paid cash? If it’s cheaper to pay for it outright, then I’m happy to leave my insurance out of the equation.
Let’s be truthful, some of us do an excellent job helping our 17-18 year old get ready for the real world even if we also remember situations when we hope they didn’t pay too close attention to our bad habits. Adult finance is complicated by some natural tendencies toward spending and savings. I’ve heard more than one parent wonder out loud how a child could grow up in their house and manage money the way they do.
Whether you have full confidence in their money management skills or expect to get several calls asking for guidance when the issue is totally out of hand, here are some tips that may help you and the 17-18 year old in your life:
Reduce their risks-
- Review your insurance policies and find out if the coverage extends to include their property while they are living away from home temporarily. If they are leaving home permanently, pick up information about renters policies and explain it to them.
- Share tips about auto insurance coverage. Remind them that valuables in the vehicle are not insured. Consider whether it makes financial sense to have them insured through their own policy. If the premium will exceed 10% of the value of the vehicle, it may be time to switch to liability only.
- If they will continue to be covered by your health insurance plan: 1) confirm they will have access to the network providers; 2) make sure they are carrying an insurance card; and 3) share a quick reminder of typical preventive services and what to plan for co-pays.
- Recommend filling out their W-4 with a 0 for withholding exemptions until they have filed their first tax return. Several part-time jobs combined together can result in underpayment of taxes due.
- Consider giving them a list of the records you save, electronically or on paper, for financial reasons.
- Give them a shredder. Not an exciting gift, but important to keep their identity intact.
Keep the door open for conversations without judgement. We’ve all done stupid things with money – why not make sure the young adult learns some lessons from you and not the hard way.
Iowa’s new legislation will allow “health benefits plans” to be sold for coverage in 2019. The health benefits contracts will not offer the ten essential areas of coverage mandated by the Affordable Care Act. Mental health, maternity care, and treatments for addiction are examples of coverage that can be dropped and may result in lower costs.
It’s important to remember the new benefits plans are not insurance. Reading the offered plan will be important to understand what is covered and your rights if you disagree with decisions to not pay a claim. The Iowa Insurance Division will not have authority over the plans and has no responsibility to review issues that arise if benefits are denied. The plans fall under ERISA laws administered by the Department of Labor.
While consumers will be able to consider selection of coverage with fewer benefits, they also will be considering a product that lacks some of the traditional back-up security used by insurance. Health insurance providers participate in a risk pool, where money can be borrowed if there are extremely high claims in any one year. The new benefits plans won’t have this protection, a reason why they are apt to be highly selective when offering coverage to clients.
Extension’s health insurance education programs encourage individuals to compare coverage to needs and to read and understand their policies. Those consumer skills will be equally beneficial when comparing health insurance policies to health benefits plans.
Yes, if you have a Medicare Card, you will be receiving a new card in the mail soon. What is different? Your Social Security Number WILL NOT be on the new card. You will have a unique Medicare Number and this will happen automatically.
Why the change? – to protect your identity. Experts have long recommended that we avoid carrying our Social Security card or our number in our wallets, because if stolen or lost people can use it to set up accounts in our name. Until now, however, people who used Medicare didn’t have a choice. It’s generally important to have your health insurance card with you, and unfortunately the Medicare card contained a Social Security number. Consumer advocates have been asking for this to change, and now it will!
New cards will be mailed between April 2018 and April 2019; not everyone will receive their new card at the same time. Here in the Midwest, the new cards will start arriving after June 2018.
After you receive your new card, destroy your old card by shredding it. Start using your new card right away. Note: If you have a separate Medicare Advantage Card, you may need to keep the old card because you still need it to receive treatment.
Share your new card and Medicare number with your doctors, pharmacists, health care providers, insurers or people you trust to work with Medicare on your behalf.
The new card is paper; you will be able to print your own replacement card if you need one. Keep the new card with you. You will need to provide your Medicare card when you need care. If you forget your new card, health professionals may be able to look up your Medicare number online.
Beware! There will be scams – so watch out for them:
- Don’t pay for your new card – it is free. If someone calls and says you need to pay for it –it’s a scam.
- Don’t give personal information to get your card. If someone calls, claiming to be from Medicare, asking for your Social Security number or bank information – it’s a scam – Hang up.
- Guard your card. Safeguard the card as you would any other health insurance or credit card. Even though it no longer contains your Social Security number, you will still want to protect your card because identity thieves could use it to get medical services.
For more information about changes to your Medicare card, check out this short video or go to medicare.gov
I often talk with people who don’t have health insurance. Mainly that happens when I’m volunteering at a VITA (Volunteer Income Tax Assistance) site, because people without insurance generally need to pay a “penalty” as part of their tax return. What I hear from many of them is this: “Paying the penalty costs a lot less than paying insurance premiums, and I never go to the doctor anyway, so why bother?”
Well… there’s another way to look at that. I recently had a conversation with an administrator of a large employer health plan. He commented that in any given year about 15% of the plan participants never go to the doctor – never use their (employer-provided) health insurance. However, as he looks at the usage data, he has observed that it is very common that when those folks start using their health insurance, they become big users. In other words, they go to the doctor often.
That bit of information struck me as SO important. People who don’t seek health care on a regular basis are likely to miss opportunities for prevention, early detection or early intervention. As a result, they end up with bigger (and costlier) health problems.
When we do outreach to help folks make informed health insurance choices, one of the major points we explore reflects exactly that reality: having health insurance is good for…
- Your finances (by minimizing the financial impact of major health events), and
- Your health (since people who have insurance are likely to have better long-term health outcomes).
So if we have health insurance, let’s ask ourselves: are we making good use of it?
Down the road, we’ll probably be glad we did!