10 best ways to make your health benefits work for you

The Department of Labor's Employee Benefits Security Administration (EBSA) administers several important health benefit laws covering employer-based health plans. They govern your basic rights to information about how your health plan works, how to qualify for benefits, and how to make claims for benefits.
In addition, there are specific laws protecting your right to health benefits when you lose coverage or change jobs. EBSA also oversees health care laws covering special medical conditions. For more information on the laws that protect your benefits, see EBSA's Website. Or call the agency toll free at 1-866-444-3272 FREE to reach a regional office near you. These 10 tips can help make your health benefits work better for you.

10 best ways to make your health benefits work for you

1. Explore Your Options for Health Coverage

You have options for health coverage. There are many different types of health benefit plans. Find out what your employer offers, then check out the plan (or plans). Your employer's human resource office, the health plan administrator, or your union can provide information to help you match your needs and preferences with the available plans. Or consider a health plan through the Health Insurance Marketplace. Visit HealthCare.gov to see the health plan options available in your area. Get information about all of your options and review it. The more information you have, the better your health care decisions will be.

2. Review the Benefits Available

Do the plans offered cover the benefits that are important to you, such as mental health services, well-baby care, vision or dental care? Are there deductibles? What are the out-of-pocket expenses you may face? Determine your needs and priorities. Compare all of your options before you decide which coverage to elect. Matching your needs and those of your family members will result in the best possible benefits. Cheapest may not always be best. Your goal is high quality health benefits.

3. Read Your Plan's Summary Plan Description (SPD) for the Wealth of Information It Provides

Your health plan administrator should provide a copy. It outlines your benefits and your legal rights under the Employee Retirement Income Security Act (ERISA), the Federal law that protects your health benefits. It also should contain information about the coverage of dependents, what services will require a co-payment or coinsurance, and the circumstances under which your employer can change or terminate a health benefits plan. You also can find many of the answers to your questions in the Summary of Benefits and Coverage (SBC), a short, easy-to-understand summary of what a plan covers and what it costs. You should receive a copy with your enrollment materials. Save the SPD, the SBC, and all other health plan brochures and documents, along with memos or correspondence from your employer relating to health benefits.

4. Use Your Health Coverage

Once your health coverage has started, use it to help cover medical costs for services like going to the doctor, filling prescriptions or getting emergency care. Using your benefits will help you and your family stay healthy and reduce your health care costs. The Patient Protection and Affordable Care Act (ACA) provides many valuable protections for people enrolled in employment-based health plans including prohibiting preexisting condition exclusions and annual and lifetime limits on essential health benefits. What’s more, many plans cover certain preventive services for free, including routine vaccinations, regular well-baby and well-child visits, blood pressure, diabetes and cholesterol tests, and many cancer screenings. You also can keep your children on your health plan until age 26. Take advantage of your benefits, especially free preventive care if your plan covers it. If you were required to pay cost-sharing for a preventive service, check your Explanation of Benefits and ensure that the provider billed the service properly.

5. Understand Your Plan’s Mental Health and Substance Use Coverage

Many health plans provide coverage for mental health and substance use disorder benefits. If a plan does offer these benefits, the financial requirements (such as co-payments and deductibles) and the quantitative treatment limits (such as visit limits) for the mental health and substance use disorder benefits cannot be more restrictive than the financial requirements or treatment limits applied to medical/surgical benefits. Plans also cannot impose lifetime and annual limits on the dollar amount of mental health and substance use disorder services, including behavioral health treatment. Some plans cover preventive services like screenings for depression and child behavioral assessments for free. Check your SPD and SBC to find out what your plan covers.

6. Look for Wellness Programs

More employers are establishing wellness programs that encourage employees to work out, stop smoking, and generally adopt healthier lifestyles. The Health Insurance Portability and Accountability Act (HIPAA) and the ACA encourage group health plans to adopt wellness programs but also includes protections for employees and dependents from impermissible discrimination based on a health factor. These programs often provide rewards such as cost savings as well as promoting good health. Check your SPD and SBC to see whether your plan offers a wellness program(s). If your plan does, find out what reward is offered and what you need to do to receive it.

7. Know How to File an Appeal if Your Health Benefits Claim is denied

Understand your plan’s procedures for filing a claim for benefits and where to make appeals of the plan's decisions. Pay attention to time limits – make sure you timely file claims and appeals and that the plan makes decisions on time. Keep records and copies of correspondence. Check your health benefits package and your SPD to determine who is responsible for handling problems with benefit claims. Contact EBSA for assistance if you are unable to obtain a response to your complaint.

8. Assess Your Benefits Coverage as Your Family Status Changes

Marriage, divorce, childbirth or adoption, the death of a spouse, and aging out of a parent’s health plan are life events that may signal a need to change your health benefits. You, your spouse, and your dependent children may be eligible for special enrollment into other employer health coverage or through the Health Insurance Marketplace. Even without life-changing events, the information provided by your employer should tell you how you can change benefits or switch plans. If you’re considering special enrollment, act quickly. You have 30 days after the life event to request special enrollment in other employer coverage or 60 days to select a plan in the Marketplace.

9. Be Aware that Changing Jobs and Other Work Events Can Affect Your Health Benefits

If you change employers or lose your job, you may need to find other health coverage. If you have a new job, consider enrolling in your new employer’s plan. Whether starting or losing a job, you may be eligible to special enroll in a spouse’s employer-sponsored plan or through the Health Insurance Marketplace. Under the Consolidated Omnibus Budget Reconciliation Act – better known as COBRA – you, your covered spouse, and your dependent children may be eligible to continue coverage under your former employer-sponsored plan. This coverage is temporary (generally 18 to 36 months) and you may have to pay the entire premium plus a 2 percent administrative charge. Get information on your coverage options and compare. Be aware of the deadlines for deciding on coverage and find out when your new coverage will be effective.

10. Plan for Retirement

Before you retire, find out what health benefits, if any, extend to you and your spouse during your retirement years. Consult with your employer's human resources office, your union, or the plan administrator. Check your SPD and other plan documents. Make sure there is no conflicting information among these sources about the benefits you will receive or the circumstances under which they can change or be eliminated. With this information in hand, you can make other important choices, like finding out if you are eligible for Medicare and Medigap insurance coverage. If you want to retire before you are eligible for Medicare and your employer does not provide health benefits in retirement, consider what you will do for health coverage. Your options may include enrolling in a spouse’s employer plan or in a Marketplace plan or temporarily continuing your employer coverage by electing COBRA. Planning for retirement includes planning for your health coverage in retirement. To find out more, read Taking the Mystery Out of Retirement Planning.

These Laws Can Help

• The Employee Retirement Income Security Act – Offers protection for individuals enrolled in retirement, health, and other benefit plans sponsored by private-sector employers, and provides rights to information and a claims and appeals process for participants to get benefits from their plans.
• The Patient Protection and Affordable Care Act – Creates the Health Insurance Marketplace and provides protections for employment-based health coverage, including extending dependent coverage of children to age 26; prohibiting preexisting condition exclusions and prohibiting lifetime and annual limits on essential health benefits.
• The Consolidated Omnibus Budget Reconciliation Act – Contains provisions giving certain former employees, retirees, spouses, and dependent children the right to purchase temporary continuation of group health plan coverage at group rates in specific instances.
• The Health Insurance Portability and Accountability Act – Allows employees, their spouses and their dependents to enroll in employer-provided health coverage regardless of open enrollment periods if they lose coverage or in the event of marriage, birth, adoption or placement for adoption. Also prohibits discrimination in health care coverage.
• The Women's Health and Cancer Rights Act – Offers protections for breast cancer patients who elect breast reconstruction in connection with a mastectomy.
• The Newborns' and Mothers' Health Protection Act – Provides rules on minimum coverage for hospital lengths of stay following childbirth.
• The Genetic Information Nondiscrimination Act – Prohibits discrimination in group health plan premiums based on genetic information. Also, generally prohibits group health plans from requesting genetic information or requiring genetic tests.
• The Mental Health Parity and Addiction Equity Act and the Mental Health Parity Act – Requires parity in financial requirements and treatment limitations for mental health and substance use benefits with those for medical and surgical benefits.
• The Children's Health Insurance Program Reauthorization Act – Allows special enrollment in a group health plan if an employee or dependents lose coverage under CHIP or Medicaid or are eligible for premium assistance under those programs. 

Read More

Health Insurance coverage update Information

What Is Health Insurance?

Health insurance is a type of insurance coverage that covers the cost of an insured individual's medical and surgical expenses. Depending on the type of health insurance coverage, either the insured pays costs out-of-pocket and is then reimbursed, or the insurer makes payments directly to the provider.

In health insurance terminology, the "provider" is a clinic, hospital, doctor, laboratory, health care practitioner, or pharmacy. The "insured" is the owner of the health insurance policy; the person with the health insurance coverage.

In countries without universal health care coverage, such as the USA, health insurance is commonly included in employer benefit packages and seen as an employment perk.

Is health insurance coverage a human right or another product one can buy?

In some countries, such as the United Kingdom or Canada, health care coverage is provided by the state and is seen as every citizen's right - it is classed along with public education, the police, firefighters, street lighting, and public road networks, as a part of a public service for the nation.

In other countries, such as the USA, health insurance coverage is seen somewhat differently - with the exception of some groups, such as elderly and/or disabled people, veterans and some others, it is the individual's responsibility to be insured. More recently, the Obama Administration has introduced laws making it mandatory for everybody to have health insurance, and there are penalties for those who fail to have a policy of some kind.

Everybody at some time in their life, and often on many occasions, will need some kind of medical attention and treatment. When medical care is required, ideally the patient should be able to concentrate on getting better, rather than wondering whether he/she has got the resources to pay for all the bills. This view is becoming more commonly held in nearly all the developed nations.

Managing diabetes - researchers from the Kaiser Permanent Center for Health Research in Portland, Oregon, found that diabetes patients need continuous health insurance coverage for the long-term proper management of their disease .

Since the late 1990s, millions of US citizens have found themselves with absolutely no health cover at all. A collection of several different studies and surveys puts the number of "uninsured" Americans at over 50 million; tens of millions more have inadequate insurance.

A Commonwealth Fund 2011 report informed that 26% of all US citizens of working age experienced a gap in health insurance coverage; many lost their health insurance when they either became unemployed or changed jobs.

Children in the USA with private insurance are considerably more likely to have a primary care physician in America compared to those with public insurance or no insurance at all, according to a study carried out by researchers at the Children's Hospital, Boston. The authors added that levels of treatment in emergency departments varied significantly, depending on what type of health insurance they had.

Americans with long-term or serious illnesses are the least able to pay for their medical bills among the leading developed nations in the world, a Commonwealth Fund International Survey reported in November, 2011.

The Affordable Care Act made it possible for young adults aged between 19 and 25 to join or stay on their parents' health plans in 2011. A Commonwealth Fund report informed that 13.7 million young adults remained or got onto their parents' health plans; this included 6.6 million people who would not have been able to do so if the Act had not been signed.

According to an eHealthInsurance survey carried out in 2010, the average monthly premiums among its customers were $167 per month for an individual, with an average deductible of $2,632. Family plans cost an average $392 per month with a $3,531 deductible.

Two broad types of health insurance or health coverage

Broadly speaking there are two types of health insurance:

• Private health insurance - the CDC (Centers for Disease Control and Prevention) says that the US health care system is heavily reliant on private health insurance. 58% of Americans have some kind of private health insurance coverage.
• Public (government) health insurance - for this type to be called insurance, premiums need to be collected, even though the coverage is provided by the state. Therefore, the National Health Service (NHS) in the United Kingdom is not a type of health insurance - even though it provides free medical services for its citizens, it does not collect premiums - it is a type of universal health coverage.
  
  Examples of public health insurance in the USA is Medicare, which is a national federal social insurance program for people aged 65+ years as well as disabled people, and Medicaid which is funded jointly by the federal government and individual states (and run by individual states), SCHIP which is aimed at children and families who cannot afford private insurance, but to not qualify for Medicaid. Other public health insurance programs in the USA include TRICARE, the Veterans Health Administration, and the Indian Health Service.

The five main types of health insurance plans in the USA

There are five main kinds of health insurance plans, with indemnity plans at one end, and HMOs (health maintenance organization) at the other end of the spectrum. POS (point-of-service plans) and PPOs (preferred provider organizations) include a combination of features from indemnity plans and HMOs; however, they are usually seen as managed care plans.

In 2003, the US Congress introduced a new option, the HSA (Health Savings Account), which is a combination of HMO/PPO/Indemnity and a savings account which has tax-benefits.

Understanding the differences between different kinds of plans is useful and extremely important when you are considering choosing one for yourself, your family, or employees. However, as plans evolve and add more details and take others away, there is more overlap and their distinctions become progressively blurred. The majority of fee-for-service plans (indemnity plans) use managed care techniques to control costs and to ensure there are enough resources to pay for appropriate care. Similarly, many managed care plans have adopted fee-for-service characteristics.

What are managed care plans?

Managed care plans are health insurance plans that have a contract with health care providers and medical facilities to provide medical care at special prices (lower costs). These providers form the plan's network. The network will have rules, which stipulate how much of the care the plan will pay for.

Restrictive plans usually cost the "insured" less, while flexible ones are more expensive. HMOs will typically only pay for care if you use one of the providers in their network. A primary care doctor (general practitioner) coordinates most of the patient's care. PPOs will cover more of the costs if the insured selects a provider within their network, but will also pay up some of the money for providers outside the network. POS plans allow the insured to choose between an HMO or a PPO each time care is required.

What are Indemnity Plans?

The insured can choose any doctor he/she wants. The doctor, hospital or the insured submits a claim for reimbursement to the health insurance company.

It is important to remember that, like any insurance plan, the insured will only be reimbursed according to what is listed and mentioned in the Benefit Summary. It is important to read the Summary carefully and understand all that is printed, even the "small print". Most indemnity plans claim to cover "the vast majority of procedures".

Coinsurance - while indemnity plans do not pay for all of the medical and surgical services, they typically pay for at least 80% of the customary and usual costs, while the insured is liable for the remaining 20 or so percent. The insured is also liable for any excess charges, e.g. if the provider charges more than what is considered as a reasonable and customary fee. Look at the example below:

Example of Coinsurance and excess charges

• You see a doctor for "diabetes care"
• The insurer deems that the customary fee for this type of diabetes care is $200.
• The insurance company pays $160 (80%), while the insured (you) is expected to pay for the rest ($40).
• However, if the provider bills you for $250, you will have to pay for those extra $50.
• So, you will have to pay $40 + $50 = $90.

The 8/20 level coinsurance ratio is only a typical example given in this article. Some plans may be 75/25 or 70/30.

Deductibles - the amount of covered expenses the insured has to pay before the reimbursement system kicks in and starts covering medical costs. The deductible total may range from $100 to $300 per person annually, or from $500 to $1,000 annually for a whole family.

Out-of-pocket maximum - as soon as the insured's covered expenses reach a certain amount during a 12-month period, the plan will cover all usual and customary fees from then on. The insured has to remember that any charges above what are considered as usual and customary by the insurance company will have to be paid for by the insured.

Lifetime limit - if the insured has a lifetime limit of $2 million, it means the insurance company will only cover costs up to $2 million during that person's lifetime. Ideally, one should have a lifetime limit of at least $2 million.

What are HMOs (Health Maintenance Organizations)?

Health Maintenance Organizations deliver care directly to the insured. The insured goes directly to an HMO's medical provider to see health care professionals. The insured does not pay for each individual service that is received. A set premium is paid to the HMO, which in return offers a range of services, including preventive care.

A primary care physician (general practitioner, GP, or family doctor), who is affiliated with the insured's plan usually coordinates the care.

In the majority of cases, the HMO will only provide coverage to specialists within the provider network that are referred by the primary care physician. The HMO will nearly always insist that the insured receive care from health care professionals, laboratories and medical centers which are within its network of providers. The HMO will have negotiated a list of fees for each medical service with them. This is done to keep costs at a minimum.

According to the majority of health insurance advisers, HMOs are usually the cheapest kind of health insurance plan.

Copayment - in most cases, the insured will also have to make a copayment for some services. Some HMOs may not require copayments for hospital stays.

What are PPOs (Preferred Provider Organization)?

A PPO is in many ways similar to an indemnity plan - the insured can see any doctor whenever they like. The Preferred Provider Organization gets together with health care providers, health professionals and laboratories and negotiates preferential prices. The providers that come to agreed deals with the PPO then become part of its network.

Copayments - when the insured visits a doctor who is within the PPOs network, they make a copayment (pay a fixed amount). When the doctor is not in the network, the PPO will still pay for some of the fees, usually at least 70%, and the insured has to cover the balance, which is known as the coinsurance, plus the copayment.

Deductibles - the insured may have to cover a certain amount of the expenses before the PPO can reimburse. As with indemnity plans, deductibles might range from up to $300 per year per person or $500 to $1,000 per whole family. When deductibles are high, premiums tend to be comparatively low.

Self-referrals - an attractive part of PPOs for many people. You can see the doctor of your choosing, including specialists not included in the insurer's network, without having to be referred to them by a primary care physician, for example.

What are POS Plans (Point-of-Service Plans)?

A POS Plan is like a hybrid of an HMO and a PPO. The insured can chose to either have a general practitioner coordinate their care, or opt to go directly to the "point-of-service".

When the insured requires medical care, there are usually two or three different choices, and they depend on what type of POS Plan is in place:

• Through a primary care physician - similar to an HMO plan. The insured is just required to make a copayment.
• PPO network provider services - the insured can receive care from a PPO provider that is within the PPO's network. The insured will have to make a copayment, and may also be liable for coinsurance (e.g. the insurer pays 80% of the bill and the insured the remaining 20%).
• Services from non-network providers - some of the medical expenses will be reimbursed. It is important that the insured reads the Benefit Summary carefully, where who pays for what, and how much, should be clearly laid out. There will usually be a copayment and a higher coinsurance charge.

Deductibles - as with the other plans, the insured may be liable for the first $100 to $300 in medical costs, while each family may have deductibles of $500 to $1,000 per year. The higher the deductibles, the lower the premiums tend to be.

What are HSAs (Health Savings Accounts)?

These are tax-free savings accounts aimed at building up coverage for future medical expenses. Only patients with a high-deductible plan and currently have no other insurance plans are eligible.

This type of plan is useful for those who are seeking some kind of protection, do not envisage having any or many ongoing medical costs, and would like to be ready for an emergency or catastrophic healthcare cost. Small businesses may find HSAs a useful alternative to the more traditional health plans on the market.

People can enter an HSA plan through their employer if such a plan is available through the company, or individually (in some states). The HSA plan needs to be paired with an existing health plan with an annual deductible of over $1,100 for individuals and $2,200 for families. There is a limit on total out-of-pocket costs, including copayments and deductibles. Limits can vary as time goes by. Even though deductibles tend to be much higher than in other plans, some of them do offer full coverage, while others offer nearly full coverage (with a small copayment for preventive care).

In general, health plans with high-deductibles have cheaper premiums; however, out-of-pocket costs are much higher. To compensate for that, the insured can contribute a certain amount of money to a tax-advantaged account - the amount as well as the details of tax benefits vary from year to year. The contributions can be used to reduce the insured taxable income. If payments are made by an employer on behalf of an employee, they are tax free. The money in the HSA plan can be used at any time for approved medical expenses.

An HSA plan can also act as a top-up for expenses the other paired plan does not cover, such as hearing aids. If the money is not being used, it can be invested; any investment growth is tax free, as long as the account holder only uses the money for medical expenses.

The USA's 25 largest health insurance companies

In 2009, the largest health insurance companies in the United States collected approximately $650 billion in premiums. The largest 25 (ranked by market share) accounted for over 60% of the total.

According to the NAIC (National Association of Insurance Commissioners), the top 25 health insurance companies in the USA in 2011 were:

• Unitedhealth Group
• Wellpoint Inc. Group
• Kaiser Foundation Group
• Aetna Group
• Humana Group
• HCSC Group
• Coventry Corp. Group
• Highmark Group
• Independence Blue Cross Group
• Blue Shield of CA Group
• Cigna Health Group
• BCBS of MI Group
• Health Net of California, Inc.
• BCBS of NJ Group
• BCBS of FL Group
• Regence Group
• BCBS of MA Group
• Carefirst Inc. Group
• Wellcare Group
• HIP Ins. Group
• Metropolitan Group
• Unumprovident Corp. Group
• Universal Amer Fin Corp. Group
• Lifetime Healthcare Group
• BCBS of NC Group

American health insurance premiums rose rapidly in ten years

Health insurance premium costs rose by 113% in the USA from 2001 to 2011. In 2011, a Kaiser Survey showed that the number of people with health insurance dropped by about 20 million in 2011 compared to 2010. In order to cope with rapidly rising premium costs, millions of people are opting for larger deductibles.

Recessions can often be good for health insurance company finances

If insured individuals keep up their premium patients, but seek medical help less, health insurance companies make more money because they spend less. It is ironic that during recessions, as people struggle financially and put off medical care, insurance companies get richer faster.

In 2011, two health insurance companies - Cigna and UnitedHealth Group said fewer people were staying in hospitals, hospital stays were of shorter duration, and medical use was down.

In 2011 many premium payers, insurance experts, economists and health care professionals wondered why the insurance industry was demanding higher premiums if their profits were shooting up . The insurance industry said it was so that they could prepare for a sudden rush in demand, which they claim would be considerable when the recession was over.

What health care coverage insurance systems exist in other countries?

Australia - has a combination of a public health system, called Medicare, and private health insurance organizations. Medicare provides free universal access to hospital care, as well as subsidized non-hospital medical treatment.

Canada - has a publicly funded universal healthcare system, which is nearly all free at the point of use. Most of the public health services are provided by private organizations. Approximately 27.6% of Canadian citizen's health care requirements are received through the private sector. Private health insurance is used to cover services that Medicare does not provide for, such as optometry, dentistry and prescription medications. Three-quarters of all Canadians have some type of supplementary private health coverage - many get this as a job perk.

A report issued in May 2012 by researchers from the Universities of Toronto and British Columbia found that about 10% of Canadians are not able to take their prescription drugs as directed because they cannot afford it.

France - The French public health insurance program was established in 1945 and its coverage for its affiliates have undergone many changes since then.

All working French citizens have to contribute from a portion of their salaries to a not-for-profit health insurance fund, which mutualizes the illness risk, and reimburses patients at different rates. Insured people's spouses and offspring are eligible to be covered in the same policies. Each fund is financially autonomous, and is used to pay for medical expenses at pre-arranged prices. Recent reforms have harmonized many prices and benefits provided by different insurance funds.

Germany - this country has Europe's longest-standing universal healthcare system, which started during the last 20 years of the 19th century. 85% of German citizens are covered by a basic health insurance policy which the state provides - this provides "a standard level of coverage". 15% have chosen private health insurance plans. WHO (World Health Organization) says 77% of Germany's health care system is state-funded while 23% comes from the private sector.

Japan - the country has an Employees Health Insurance and a National Health Insurance system. The National Health insurance is aimed at those who are not eligible for Employees Health Insurance. Even though the country also has private health insurance, everybody in Japan, including foreigners with a one-year visa must be enrolled in an Employees Health Insurance plan or National Health Insurance.

United Kingdom - the NHS (National Health Service) provides free medical and hospital care and subsidized or free prescription medications to all its citizens. The NHS is a publicly funded universal healthcare system, which is not really an insurance system as no premiums are collected and costs are not charged at patient level. Nevertheless, the NHS achieves the same aim as insurance in spreading financial risk arising from ill-health. All NHS costs are met directly from general taxation.

The UK also has private health care which is paid for mainly by private insurance. Less than 8% of the country's population has any private health insurance. The largest private health insurance companies in the United Kingdom are BUPA, AXA, Aviva, Groupama Healthcare, PruHealth, and WPA.

Read More

Health Insurance plans Medicaid and Medicare

Medicaid provides medical assistance to certain individuals and families with low incomes and resources. It is jointly funded by the Federal and State governments. Although the federal government establishes national guidelines, each state has the authority to establish its own eligibility standards, determine the type and duration and scope of services, set the rates of payments and administer the program. Eligibility criteria can be found on the Centers for Medicaid and Medicare Services (CMS) website at: http://www.cms.hhs.gov/MedicaidGenInfo/

As part of the plan, the state must offer medical assistance for certain basic services to those living under the poverty level. For adults over the age of 21, the states are not required to provide speech-language pathology and audiology services. To ascertain the coverage in your state, you should contact the state Medicaid agency. The following website will assist you in locating your state agency: http://www.cms.hhs.gov/MedicaidGenInfo/
For children under the age of 21, the Medicaid law requires the states to provide hearing screenings and assessment of communication skills and language development as part of the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) service. Based on the findings of this screening, the state must provide services and related devices such as hearing aids and AAC devices to treat or ameliorate the condition. To find out more about EPSDT.
Medicaid recognizes the importance of school-based speech-language pathology and audiology services although it is a medical assistance program. The federal Medicaid program actually encourages states to use their Medicaid programs to help pay for certain health care services delivered in the schools if federal regulations are followed. Contact your local school district to inquire if they participate in the Medicaid program.

Medicare

In 1965, the Social Security Act established both Medicare and Medicaid. Medicare is the federal health insurance program that is designated for those people who are 65+ years of age. Although directed towards a specific age bracket, Medicare plans are also applicable to certain disabled people.
Medicare covers most services for assessing and treating speech, language, swallowing, hearing and balance disorders. It covers most hearing examinations but it does not cover hearing aids or tests for hearing aids.
Medicare has two major parts: Part A is hospital insurance and is financed through federal taxes while Part B is supplementary medical insurance and has a monthly premium.
Medicare Part A helps cover hospital stays, limited skilled nursing facility care when daily skilled services are needed, home health care and hospice care. Most services for speech, language, hearing and related disorders such as those effecting swallowing and balance are covered in these settings. Medicare regulations allow rehabilitation services when significant functional progress is expected and/or maintenance care is needed.

Medicare Part B helps cover physician services, audiology testing services, outpatient hospital services, rehabilitation agency services and comprehensive outpatient rehabilitation facility services. Service for speech and related disorders are covered in these settings.

Read More

Private health plans of about health Insurance

Understanding health insurance plans can be confusing to most consumers. Many don't know where to look or whom to contact for information on the coverage of speech-language pathology services, audiology services and hearing aids, let alone how to interpret the coverage guidelines. ASHA has developed this site to help you, as a consumer, understand your health plan as well as provide further contacts to assist you in understanding and obtaining the coverage you need to receive speech and hearing services.

Private Health Plans

Typically, a health benefit plan is a contract between your employer and a third party (an insurance company). These contracts vary widely depending on the benefits and coverage levels negotiated by your employer. Oftentimes, the benefits information provided by your health plan is confusing-leaving you unsure of what speech and/or hearing services will or won't be covered.
Remember, the benefits booklet you receive is merely a summary of benefits-not actual contract language. You may need to examine the policy or contract to truly understand your health plan's coverage and limitations. The policy or contract can be obtained from your benefits manager.
It is vital that you review the speech and hearing benefits information provided by your health plan and employer before you receive services.

Tips and strategies for ensuring that speech and hearing services are covered

Understand Your Benefits

Some things to look for when reviewing your health plan benefits booklet are:

1.     Terms such as "speech-language pathology," "speech pathology," "speech therapy," "hearing care, "audiology,".

o    Coverage information for speech and hearing services may also be included under “physical therapy and other rehabilitation services “or "other medically necessary services or therapies."

o    Hearing services may be found under diagnostic services.

2.     Coverage of both assessment ("testing") and treatment ("therapy") services for hearing and speech disorders.

3.     Limitations and exclusions are typically located in a separate section often referred to as "Things We Don't Cover" or "Exclusions to Coverage".

Common limitations and exclusions include:

• No coverage for speech and/or hearing disorders that have a developmental or congenital cause.
• Coverage for acquired disorders only or only for treatment that is restorative or rehabilitative.
• No coverage for certain disorders, such as stuttering and autism.
• A limit on the dollar amount that will be reimbursed for speech and/or hearing services.
• A limit on the number of speech and/or hearing therapy sessions that will be reimbursed.
• Coverage may also be limited to certain settings such as a hospital or clinic.
• No coverage for devices such as hearing aids or speech-generating devices.

When in doubt, check it out! If you are unsure about the coverage your health plan provides for speech or hearing services call the 800 number listed on your ID card and speak to a customer service representative. Request that they provide any clarification of your coverage in writing .
Remember to keep copies of all documentation, including date, time, and contact person!

Get Permission before Your Visit

Your health plan may require that you obtain prior approval or that a physician "prescribe" speech or hearing services. This may also be referred to as "pre-authorization", "pre-certification" or "pre-determination". Read on to find out the subtle differences between these three terms.

• Pre-authorization is how the health plan verifies your coverage against the proposed care.
• Pre-certification requires that you notify the health plan before undergoing certain diagnostic or surgical procedures. The health plan assigns an authorization number.
• Pre-determination is a health plan requirement in which the provider must request confirmation from the health plan that the service or procedure to be performed is covered under your policy.

Every private health plan is different, so you'll need to call the 800 number listed on your ID card and speak to a customer service representative to determine what speech or hearing services need prior approval. Unfortunately, prior approval does not always guarantee coverage.
Always check with your health plan before having any service performed.
Remember to keep copies of all documentation, including date, time, and contact person!

Educational vs. Medical Issues

Children have access to speech and hearing services through the school system as well as through the medical system. Each system however, has specific policies.
School systems provide speech services only to children who qualify under a very rigid set of federal regulations and state education laws. Children who do qualify for speech services in the school system may be placed on a waiting list. Furthermore, speech-language pathologists, who provide speech services in the schools, typically have more children on their caseload than recommended. Supplemental therapy, from a provider outside of the school system, reduces the time children spend in treatment.
Only when families seek supplemental services from their health plan, do they discover that the majority of private health plans will not pay for services that may also be provided in a school setting. As a result, the child becomes the ping-pong ball that bounces between the school and medical systems- all the while not receiving needed services.
Communication disorders affect an individual's health and education simultaneously. Therefore, children are best served when providers (speech-language pathologists and audiologists) from both the school and medical systems work collaboratively to identify the best treatment setting for each child. Many times, children attain their best potential by being served in both settings simultaneously.

Submitting a Claim

Some speech-language pathologists and audiologists will file claims for services rendered, whereas others may request that the patient file the claim with their health plan.
If the speech-language pathologist or audiologist has signed an agreement with your health plan, they are required to file the claim. If not, they may provide you with the necessary information to be attached to the claim form. Most private health plans require specific codes for the diagnosis and treatment provided.
If you file the claim with your health plan:

1.     Fill out the claim form provided by your health plan. Print legibly and be thorough!

2.     Determine how quickly you need to file the claim. Some plans require claims to be submitted within a certain number of days. This information can be found in your summary of benefits.

3.     Attach any required documentation such as a treatment plan or physician referral.

4.     Keep copies of all documentation, including date, time, and contact person!

Appealing Denied Claims

Your health plan may deny reimbursement claims for a variety of reasons. But, you have the right to appeal your health plan's decision.
Don't procrastinate! Most states mandate the timeframe in which appeals must be processed. Once an appeal is filed, the health plan must also respond within a specified time period.

Preparing to Appeal

• Know your health plan's claims appeals process before you begin. This will allow you to gather the information required by the health plan (e.g., documentation of services, health plan language).
• Obtain the health plan's rationale for the denial in writing. This is commonly referred to as an Explanation of Benefits (EOB). The EOB will tell you why the health plan denied the claim.
• Review the actual contract language NOT the benefits summary to determine if the service is listed as a benefit under your plan.
• If the claim is being denied because the service is not a covered benefit:
• Review the actual contract language (See "Coverage" section above). Is the service listed as a benefit? If so, submit that page with your appeal letter.
• Ask your physician to prepare a letter in support of coverage.
• If the claim is being denied because the service is not medically necessary:
• Determine if the service is a recognized treatment for your condition. For a service to be considered medically necessary, you will need to demonstrate that the service:
• was or is being performed for a medical reason,
• is usual and customary treatment for your condition; and
• is ordered by a licensed physician (if required).
• Ask your physician to prepare a letter in support of coverage.

The Appeal Letter

Prepare an appeal letter that includes:

1.     patient's name,

2.     subscriber's name,

3.     health plan identification number,

4.     date of service; and

5.     the reason why you are appealing the denial.

Request a review of the claim by a speech language pathologist for an appeal of speech services or an audiologist for an appeal of hearing services.
Gather the necessary supporting documentation (e.g., EOB, pertinent pages from your benefits booklet, treatment plan, test results, letters of support).
Address the appeal letter to the appropriate health plan representative. If you have not identified this person, call your health plan's customer service department and request the name and address of the person or department to which appeals should be addressed.
Send the appeal letter and supporting documentation via certified mail, return receipt requested. Be sure to keep the return receipt with the signature from the health plan representative.

After the Appeal

Register a complaint with your state insurance commissioner if you:

• believe the claim is being denied unfairly,
• have difficulty obtaining a copy of your policy; or
• are not getting information in a timely manner.

To register a complaint, go to the National Association of Insurance Commissioners Web site. The Office of the Insurance Commissioner or State Insurance Department regulates insurance.
The insurance commissioner will contact your health plan if your complaint warrants investigation. Health plans take complaints to the state insurance department very seriously.

• Follow up with the health plan representative regularly to check on the status of the appeal.
• Keep copies of all documentation, including date, time, and contact person.
• Continue to appeal claims denied by the health plan as it may take more than one appeal to reverse a health plan's denial.
• Be patient! Be persistent! Don't give up!

The External Review Process

If the appeal is denied, you have exhausted the health plan's internal appeals process, and you still believe your treatment meets coverage definitions, consider taking the case to the external claim review level. Currently, 42 states have an external review process (go to the Kaiser Family Foundation's Consumer Guide to see each state's procedure and contact points).

Read More