Healthcare Resources

Are you a retiree who buys your medical insurance on the open market, rather than through a group plan like PEBB or Boeing? If so, here are some questions to research when comparing Traditional Medicare vs. Medicare Advantage:

Do you want to go to any doctor of your choice who accepts Medicare in the US without an insurance-mandated referral, and with prior authorizations* very rarely being required? In that case, Traditional Medicare (Parts A and B) plus Medigap Plan G and a Medicare Part D plan for prescription drug coverage (each purchased separately) might be for you. Then other than paying the premiums and the Part B annual deductible (currently $257), Medigap Plan G pays 100% of all remaining Medicare medical expenses for the rest of the year.

Or:

Do you want a plan with a lower monthly premium, often $0, and often with additional benefits Medigap does usually not offer such as vision, hearing, dental and gym membership? If so, are you willing to accept, as a trade-off, a limited provider network, referrals needed to see a specialist, possible increased limitations and costs for stays in rehabilitation and skilled nursing facilities, higher out-of-pocket maximums that can range from $5,000 to $9,000 a year, and many treatments subject to prior authorization by the insurance company? If so, a Medicare Advantage plan that offers both medical and drug coverage might be for you.

Do you need additional help? SHIBA volunteers provide free, impartial help with questions about choosing or changing Medicare plans. Go to insurance.wa.gov or call 800-562-6900 for more information.

*  Note: Prior authorization means that your insurance company decides in advance separately from your physician whether or not a medical treatment, service, procedure, or prescription medication is deemed medically necessary. The insurance company can therefore deny a treatment prescribed by your doctor.

Many people are surprised to learn how intertwined Medicare is with the Social Security Administration (SSA). For that reason, it can be confusing to know which agency to contact for assistance and information.

For example, the following actions should be taken with the Social Security Administration:

• Checking Medicare eligibility,
• Signing up for Medicare Parts A & B,
• Applying for Extra Help with Prescription drug coverage (Part D),
• Appealing an income-related monthly adjustment amount (IRMAA), and
• Reporting a change in address or phone number if the beneficiary already receives benefits.

In contrast, Medicare should be the source of information for the following issues:

• Understanding what Medicare covers,
• Checking the status of Medicare Part A or B claims, and
• Finding forms for filing a Medicare appeal or letting someone speak with Medicare on a beneficiary’s behalf.

Some actions can be taken with either SSA or Medicare, such as requesting a replacement Medicare card or finding publications about Medicare.

• See medicareadvocacy.org/helpful-hint-who-to-contact-social-security-or-medicare/ to download a one-page fact sheet.

An Explanation of Benefits (EOB) statement summarizes the costs of your healthcare services and how your health insurance plan processes the claim. It’s not a bill but a statement of how your plan applied coverage.

Tips for reading your EOB:

• Review the claim details to ensure the services and dates are accurate. 
• Check the amount paid by your insurance and compare it to the total amount charged. 
• Understand how your deductible, coinsurance, and copays are applied. 
• If you have questions about your EOB, contact your insurance provider or your doctor’s office. 

An EOC (also known as a “Certificate of Coverage”) is a document that can answer many questions about a Medicare Advantage plan or a Part D prescription drug plan. It gives you important, in-depth details about what the plan covers and how much they pay.  It provides the information you need to find out if the tests, procedures, and medication your doctors advise are covered by your plan, as well as how to file an appeal. If you have Traditional Medicare (Parts A and B) you won’t get an EOC because it and your Medigap plans are standardized. For these plans, refer to the Medicare and You handbook available at Medicare.gov

All health plan companies are required to provide an SBC for each of their different plans. When you’re making decisions about buying a plan or using your benefits, an SBC can be a useful tool to help you compare costs and understand coverage options.

Here’s a step-by-step look at what information is in an SBC:

• An overview of what’s covered
• An explanation of what’s not covered and/or the limits on coverage
• Information on costs you might have to pay — like deductibles, coinsurance and copayments
• Coverage examples, including how coverage works in the case of a pregnancy or a minor injury
• A reminder that the SBC is only a summary. To get all the details, you’ll want to look at complete health plan documents.
• Information about where to go online to review and print copies of complete health plan documents
• Where to find a list of network providers
• Where to find prescription drug coverage information
• Where to find a Glossary of Health Coverage and Medical Terms (also called a “Uniform Glossary”)
• A contact number to call with questions
• A statement on whether the plan meets minimum essential coverage (MEC) for the Affordable Care Act (ACA)
• A statement that it meets minimum value (plan covers at least 60 percent of medical costs of benefits for a population on average)

A medical deductible is the amount of money a person has to pay out-of-pocket for covered healthcare services before their insurance company starts paying. Once the deductible is met, the insurance typically begins covering a portion of the remaining costs, often in the form of coinsurance or copays. 

A prescription drug deductible is the amount of money you’re required to pay out-of-pocket for your covered prescription drugs before your health insurance plan starts to cover any portion of the cost. Until you reach your deductible, you’re responsible for the full cost of your prescriptions. 

Information coming soon.

HMO (Health Maintenance Organization) and PPO (Preferred Provider Organization) are both types of managed care plans, which aim to manage healthcare costs and quality. HMOs generally offer lower premiums and copays but require you to choose a primary care doctor who coordinates your care and referrals to specialists within the network. PPOs have higher premiums but offer more flexibility, allowing you to see specialists and out-of-network providers, though at a higher cost. 

Here’s a more detailed breakdown:

Managed Care Plans: 

• Definition: Health insurance plans that aim to manage healthcare costs and quality by contracting with specific providers and facilities to provide care at reduced rates.
• Goal: To keep costs lower and quality high by negotiating with providers.

HMO (Health Maintenance Organization):

• Network: Limited to a network of specific doctors, hospitals, and other providers. 
• Cost: Typically lower premiums and out-of-pocket costs. 
• Primary Care Doctor: Requires you to choose a primary care doctor to coordinate your care and referrals to specialists within the network. 
• Flexibility: Limited flexibility; you must typically stay within the network to be covered. 

PPO (Preferred Provider Organization):

• Referral: Typically doesn’t require referrals from a primary care doctor to see a specialist. 
• Network: Offers a broader network of providers compared to HMOs. 
• Cost: Generally higher premiums and out-of-pocket costs than HMOs. 
• Flexibility: Allows you to see specialists and out-of-network providers, but you’ll pay more for out-of-network care. 

The main difference between a copay and coinsurance is how the cost is shared with your health insurance plan. A copay is a fixed amount you pay for a specific service, while coinsurance is a percentage of the total cost for a service, paid after you’ve met your deductible. 

Even if you are happy with your plan, it is very important to check every year during your open enrollment period to see if your doctors, your pharmacy, and your prescribed drugs are covered for the following year. Insurance companies add and drop providers, pharmacies and drugs on a regular basis!

Ms. Iam Sick goes to the ER for fever, cough, and shortness of breath.  After she’s been checked over, she’s transferred to an inpatient unit for further treatment. Once she’s settled into her hospital bed, she calls her family to tell them she’s an inpatient on floor 4 North.

But is she? There are two kinds of hospital status:

You’re an inpatient starting when you’re formally admitted to the hospital with a doctor’s order. The day before you’re discharged is your last inpatient day.

Otherwise, you’re an outpatient even if you spend one or more nights in the hospital.

Why does this matter?

Your status may affect whether Medicare will cover the cost of care you get in a skilled nursing facility (SNF) following your hospital stay. This happens often for older adults who need residential medical care after being hospitalized. For traditional Medicare (check your policy for Medicare Advantage plans), you must spend 2 midnights as an inpatient on an inpatient unit.

Your hospital status—whether you’re an inpatient or an outpatient—may also affect how much you pay for hospital services (like X-rays, drugs, and lab tests).

Remember, even if you stay overnight in a regular hospital bed, you might be an outpatient. Ask the doctor or hospital. To learn more, visit https://www.medicare.gov/coverage/inpatient-hospital-care/inpatient-outpatient-status

Traditional Medicare (such as Part B plus a Medigap plan) usually pays for almost everything your health care professionals order, without requiring prior authorization for payment.  But for-profit Medicare Advantage plans often deny prior authorizations of treatments, particularly for higher cost services, such as inpatient hospital stays, skilled nursing facility stays, and chemotherapy.

The answer is often YES, because only 12% of prior authorization denials were appealed, but over 81% of those denials we overturned or partially overturned on appeal!

Contact your health care provider, as they may have submitted paperwork with the wrong billing code. Your health care provider will likely submit the appeal on your behalf, since they can best provide additional information for why the treatment, procedure or equipment is needed.

If that doesn’t work, carefully follow the steps outlined in the “Evidence of Coverage” document available from your Medicare Advantage plan. It is very important that you create a document log listing all of the communications (phone calls, emails, written) you receive or initiate (individual’s name, title, role, company, content, etc.).

Keep a running log of phone calls, emails, and written correspondence sent via U.S. Mail. This information is needed if you appeal denials of drugs and/or procedures, as well as a payment decision. You can also request a peer-to-peer review of denials from your healthcare provider, so keep a log of those calls, as well. It will also be helpful if you receive poor customer service and need to talk with a Plan Administrator. Keep your log simple. Track the following information for every phone call to your insurance company, health services provider(s), pharmacies or durable equipment retailers. Here is a sample guide:

• Date & time
• Name of person answering your call
• Your question(s) and their response to your question(s)
• If transferred, time of transfer, name of person to whom you are transferred, their title, department and direct phone number. Include their response to any different/additional question(s).
• Time call ended. If necessary, add further notes about the call—person(s) politeness, if confused by question(s) vs knew answer right away, if you were transferred to the correct person, etc.

Track the following information for emails and correspondence:

• Log all written correspondence in order by date, including sender’s name, title, organization, subject and deadlines for required action.
• Hard copy or online folder to store all emails.
• Hard copy of the correspondence received or scan it into your online folder. Note the date you received it on the document.

When your doctor says you need a particular medication or treatment, your insurance company may tell you they won’t pay for it. We believe YOU SHOULD NEVER TAKE NO FOR AN ANSWER, at least not without a fight. The good news is that insurance companies often overturn denials when they are appealed, but unfortunately very few people actually file them. Be one of those who do! Here is how:

1) Call your doctor’s office as soon as you receive a denial notice. Often they can file an appeal for you. For example, many denials are due to the doctor’s office miscoding their claim, or they sent insufficient information.

2) Keep a detailed record of all communications during your appeal process, noting dates, names of representatives, specific reasons provided for the denial, and other information discussed.

3) If your doctor’s office couldn’t help you, contact your insurance company. Ask for a detailed explanation of why your claim was denied and for them to also send you the explanation in writing. 

4) If the reasons for denial seem unjust or unclear, ask the insurance company to send you detailed instructions and forms on the appeal process.  The information is also available on their website. 5) If you versus your doctor’s office must file the appeal, follow instructions carefully, and give clear and detailed answers. You should describe the service or treatment you need and the specific reasons for the claim denial. You can also call the Washington State Office of the Insurance Commissioner for advice and assistance at 800-562-6900.