Medical Insurance Information - Arden Ensminger
Arden is the Financial Director for Breastlink. He has assisted hundereds of women with insurance queries and financial suport. He is an expert on different types of insurance for breast cancer patients.
This article will attempt to clarify the types of insurance available to women with breast cancer in the United States. The descriptions of each category are intended as a guide only. Due to the nuances of every insurance plan, we would advise you to check with your human resource department or insurance company for further information.
No Insurance
Some of us may find ourselves in this situation at one point or another in our lives, but do not let this stop you from obtaining the medical care you deserve. A good number of physician's offices will discount their fees because they are receiving payment up front without the hassles of dealing with insurance companies. If you cannot afford to pay all the costs up front, many physicians will work out a payment plan over time. Certain patients will qualify for government-funded insurance programs.
Medi-Cal/Medicaid
You can qualify for government-funded insurance if your income is below a certain level. The payment to doctors is very little, which limits the amount who contract with this type of insurance. In 2004 Medicaid was faced with some serious cuts to reimbursements, making many physicians think about whether they could continue the contract. For now, it looks like there is a moratorium on the cuts while this issue works its way through our legal system. Many hospitals participate in the Medicaid program so emergency services and hospital admissions are almost always covered.
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PPO
Preferred Provider Organization (PPO), also known as discounted fee for service, was designed to save both the insurance company and patients' money and time for services rendered. Doctors who participate agree to accept a contracted rate of payment on services and will not balance bill patients for any amount above the contracted rate. Patients who want to maximize their benefits will only select physicians from a directory that is provided by their respective insurance company. The authorization process for services is much easier and the patient can choose which doctor she will see. If you choose to see a doctor outside of the network, non-participating, then your out-of-pocket-costs could be significantly higher.
Indemnity Insurance
Due to increasing premiums and out-of-pocket expenses, this type of insurance is considered part of the endangered species list. There are no contracts between the doctors and insurance companies in order to control costs. Deductibles are typically higher than a PPO, but the trade-off is your complete freedom to choose any physician or hospital. You should consider indemnity insurance if money is not of great concern.
HMO
The 1990s saw the advent of the Health Maintenance Organization (HMO) to counter the rising costs of heath care. The HMO pays a fixed monthly payment to the physician, known as capitation, to provide all medically necessary care, which includes visits, surgical procedures, referral to specialists and hospital care. This model was designed to shift the financial risk of your care from the insurance company to the doctor. Please note that there are several different variations for remuneration between the physician and the HMO, but this is the most common method. The biggest advantage with an HMO is a relatively small amount of money out of your pocket compared to a PPO or Indemnity Insurance. The biggest disadvantage with an HMO is the large restriction on freedom of choice.
In a nutshell this is how it works. The primary care physician (internist, family medicine, OB/GYN) acts as a gatekeeper. All services are either rendered by the gatekeeper or authorized by him/her for a specialist services. The gatekeeper belongs to an independent practice association (IPA) that provides authorizations for all medically necessary services. Another layer is inserted with the creation of a utilization review committee that must approve the written request of any non-emergency service unable of being performed by the gatekeeper. The committee usually meets once a week to approve or deny based on medical necessity or less expensive alternatives.
Before joining an HMO (if you have a choice and economics is not a major factor) consider the following: Do you want someone telling you what doctors or procedures you can have? Will you stand up for yourself if you feel that you are not receiving proper care? Do you want freedom of choice?
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POS
The Point of Service (POS) plan combines an HMO, PPO and sometimes the Indemnity part, together presenting you with the complete package. For those services that can be treated by your primary care physician (PCP) you will utilize your HMO at a low cost to you. If you want to choose which doctor you will see within the network without an authorization from your PCP, utilize the PPO portion. If you want to see a physician that does not participate with your network, utilize your Indemnity part. This plan can be tricky, so be prepared and educate yourself with your particular plan before using it.
Medicare
Upon retirement or permanent disability you may qualify for Medicare. Medicare contracts with physicians to agree to a discounted fee for service and therefore "accept assignment." Accepting assignment means that the doctor agrees to bill only you for the 20% allowed under the contract and your deductible. Please do not confuse accepting assignment with not paying any money out of your pocket. You can add secondary insurance coverage in order to lessen or eliminate your 20% share of cost.
Medical Savings Accounts
This method allows you to have greater control over your health care. For example, currently your employer pays $6000 a year for your traditional health insurance with a $250 deductible, and you pay 20% out of your pocket up to a maximum of $3000 per year. Instead, your employer pays $3500 for a catastrophic plan with a $2500 deductible and places the savings of $2500 in a Medical Savings Account (MSA). When you use your insurance, the $2500 from your MSA would satisfy the deductible and your insurance would be activated to pay the rest. If at the end of the year you have used only $1000, the remaining $1500 would roll over and continue to grow in a tax-free account for future health care needs or retirement. You benefit by keeping any money not used and your employer benefits by lowering the cost of insurance for the company. Only the self-employed or a business of 50 persons or fewer can qualify for an MSA. Also, the individual deductible must be between $1650 and $2500, or a family deductible of between $3300 and $4950. The out-of-pocket maximum for individuals is $3300 and $6050 for families. Other restrictions apply so please consult your insurance broker or agent for details. The MSA will end December 31, 2004 so please read the next section on Health Savings Accounts.
Health Savings Account
On December 8, 2003, President Bush signed into law the next generation of MSA plans, called the Health Savings Account (HSA). 2004 is a transition year for the MSA because it will end December 31, 2004. Those who have qualified for a MSA will now qualify for a HSA. The HSA replaces the MSA with fewer restrictions. All size employers are now eligible to participate and the deductibles have a broader range. The minimum deductible is $1000 for an individual and $2000 for families. The out-of-pocket maximum for individuals is $5000 and $10,000 for families. The concept of keeping any unused money from year to year remains intact.
Tax Deductions
Domestic tax laws and international tax laws will vary on how much you can declare as a deduction. Medical expenses are not just monies you have paid to your doctor but include fees for medical conferences, alterations to your home prescribed for your medical condition, travel-related expenses and mileage to get your medical care, prostheses and salves or lotions for wound and skin care related to your medical condition. Remember to keep all receipts and consult with your tax advisor for professional advice.
Conclusion
We have tried to present to you all your medical insurance options in a succinct manner. Unfortunately, we could not expound upon the idiosyncrasies of each plan but provided a brief overview. Some of you have coverage through an employer and therefore cannot change plans. For those of you who have a choice, please consider every option and make an informed decision. And remember, no matter what restrictions or absence thereof be a vocal part of your medical treatment.
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