Choosing the right health insurance plan can be overwhelming. It may be tempting to just keep the plan you currently have rather than look at spreadsheets and dense, hard-to-decipher descriptions of coverage options.

That’s a mistake. Whether you’re over 65 and inundated with advertising about Medicare open enrollment options or getting your insurance through the Marketplace or working for a company whose annual open enrollment is taking place this fall, it’s imperative that we review our current plan and see what our options are for 2023.

Here are some things to keep in mind regardless of where you get your health insurance:

• It’s not all about premiums. To get a sense of how much you may spend during the year, you need to look at all costs including deductibles, co-pays, co-insurance, out of pocket maximums. Click here for an article that defines these and other key health insurance terms.
• The provider network may or may not matter to you. It’s a personal decision whether you want to trade lower costs for having to switch doctors, travel further, or have a smaller network to choose from.
• Look at the health care services you think you’re most likely to need and try to find a plan that meets your specific needs. For example, if you know you’re going to need a lot of physical therapy (PT) next year, it may make sense to pay more in premiums for a plan that provides better coverage of PT visits.
• Do you have a second home in another state? Provider networks will be important in this scenario.

Medicare
Medicare Open Enrollment started October 15 and you can’t watch TV these days without seeing commercial after commercial about different Medicare insurance options. During Medicare Open Enrollment you can:

1. Switch from Original Medicare to Medicare Advantage
2. Switch from Medicare Advantage to Original Medicare
3. Switch from one Medicare Advantage plan to another Medicare Advantage plan
4. Switch from one Part D (prescription drug coverage) plan to another Part D plan

A few tips:

• Be sure to check the formulary (list of covered medications) in your current Part D plan and any Part D plans you are considering to make sure your medications are included. You can do this on Medicare Plan Finder.
• If you’re in a Medicare Advantage plan, be sure to check whether your providers will still be in network next year.
• You can download the Medicare Open Enrollment guide from the Medicare Rights Center.
• This article, 3 Ways to Prepare for Medicare Open Enrollment, has helpful advice. 

Health Insurance Marketplace and Employer Health Plans

• Open enrollment for the Health Insurance Marketplace/Exchange is from November 1 - January 15.
• Open enrollment timing and options for employer-based plans vary. 
• For either, here is some helpful advice about Choosing A Health Plan from FAIR Health.
• More general advice about open enrollment for health insurance and other benefits can be found here and here.

Bottom line: Be sure you understand your options, get your questions answered, and know your preferences (cost, access, convenience, willingness to accept risk, etc.) before you make a decision. Contact me if I can help answer questions or conduct an analysis for you. 

We know that providers should use plain language when speaking with patients, yet we also know from experience that that is often not the case. Providers may often rush through instructions as well. And not every provider’s office gives you an after-visit summary or provides a plain-language after-visit summary.
What is teach-back? According the Agency for Healthcare Research and Quality, “the teach-back method is a way of checking understanding by asking patients to state in their own words what they need to know or do about their health. It is a way to confirm that you have explained things in a manner your patients understand. The related show-me method allows staff to confirm that patients are able to follow specific instructions (e.g., how to use an inhaler).”

While teach-back is actually a method that providers should be trained in and use, we also know that they usually don’t. As patients, we can initiate a “teach back” moment ourselves! 

After your doctor tells you something, such as your diagnosis or treatment plan, repeat it back in your own words. That way, they can determine if you understood the instructions and it gives them an opportunity to make corrections.
For example, suppose you have diabetes and monitor your blood sugar level at home. The doctor explains to you what to do if your blood sugar is low or high. After they explain this to you, they should ask you to repeat it back to check for understanding. This understanding should include what range is low, what range is high, and what to do in each case. If the doctor doesn’t ask you to repeat it back, you could initiate the teach-back yourself: “Dr. Smith, I just want to be sure I understood correctly. If my blood sugar is low [give number], then I should eat or drink [give example]. If my blood sugar is high [give number], then I should [give example].” If you get this wrong, the doctor knows that they need to repeat the instructions, perhaps using different language or approach.

Teach-back is not a quiz for patients; it’s actually puts the onus on providers to explain information clearly. However, since I’ve rarely seen it used in practice, I recommend that we, as patients, take this into our own hands and use it for ourselves!

Bottom Line: We need to advocate for ourselves. One way to be sure that we understand information correctly is to use the teach-back method.

A few months ago, my friend’s daughter, a freshman in college, had a health scare. Fortunately, everything turned out okay! But my friend hadn’t had her daughter fill out any of the necessary forms to allow the doctor and hospital to release information to her or even to speak to her about her daughter’s medical concerns. Trying to get a busy (and uninterested) college student to fill out the necessary forms while in another state in the middle of a semester was not quick, easy, or painless. ​

There are privacy laws (HIPAA) that restrict what a health care provider can share about any adult 18 years or older. Yes, this applies even if your adult child is still on your health insurance plan and even if you are paying the bills. Please refer to this article with advice about what forms you should have your 18+ year-olds sign. You can complete these forms on your own or meet with an estate planning attorney.

Briefly, the four important documents are:

1. Health Care Power of Attorney - this allows you to designate someone to serve as a your proxy or agent in case you are unable to make medical decisions on your own (Illinois form).
2. HIPAA Authorization - a document that allows health care providers (and others) to share specific health information with people who you designate to receive that information (sample form from the American Bar Association). Many health care systems have their own forms as well.
3. Durable Power of Attorney/Power of Attorney for Property - allows you to designate someone to act on your behalf for financial matters.
4. FERPA Release (Family Educational Rights and Privacy Act) - permission to access educational records. The student must fill out this form, which is available from their college.

If your adult child is attending college in another state, it may be safest to fill out forms for each state. Some colleges have their own forms as well (e.g., the University of Illinois has this authorization to release confidential health information form); this is something worth asking about at parent orientation.

Note that it is never - regardless of the person’s age - enough to just write the name of the person who you want to be your health care power of attorney. It’s critical to first ask them if they are willing to take on this role, if needed, and then have an in-depth conversation about your wishes.

Once you’ve filled out the forms, keep them in a secure place. Also, be sure to scan them so you can easily access them from your phone as well as from your child’s phone.

Bottom Line: while you’re checking towels, sheets, comforter, etc off of your college packing/to do list this summer, please add “fill out important forms!"

​I think we’re all aware that there is a mental health crisis in this country. As a result, it can be REALLY difficult to find a therapist who has availability, much less a therapist with availability who is in your health insurance network. Are you stuck paying out-of-pocket for the entire amount? Maybe not!

In the past couple months, I helped a client with her network gap exception request as well as advised a friend how to request one. In both cases, these exception requests were approved. 

So, what does this mean and how do you get your request approved?

Suppose you have a child with anxiety who needs to be seen by a mental health provider. You request a list of in-network providers from your insurer. You call each provider who is located within a reasonable distance and are told that none of them have any availability for new patients… or perhaps they are taking new patients but only self-pay patients. Your child needs help, so you end up finding someone who will see your child and you pay 100% out-of-pocket.

Now, you should be thinking: I’m going to call my insurer and request a network gap exception!

Call the customer service number on the back of your health insurance card. Tell the  representative that you’d like to request a network gap exception. This is the information that you’ll need before you make that call:

• name, address, phone number of provider
• NPI number of provider (Google the provider’s name and “NPI” or call the provider and ask)
• Tax ID number (EIN) of provider (call the provider’s office)
• Diagnosis (CPT or diagnosis code or, e.g, “OCD”)
• Reason why you are making this request (eg, “I have called all 25 providers who are in-network within a 30 minute drive and none are taking new patients,” or “none of the providers who are in-network treat complex PTSD.”)

It’ll take about 30-45 days to hear back.

What happens if you are approved?

• You may be approved for a set time frame or for a set number of visits
• You will have to submit the claims or a superbill to the insurer (ask them for the correct claims form)
• Remember that your insurer is agreeing to reimburse YOU at their in-network rate. Your provider is NOT agreeing to be an in-network provider. Therefore, you will owe your provider their entire fee. The bonus for you is that you are getting reimbursement for part of that fee.

While, I am focusing on mental health providers here, you can request network gap exceptions for any type of provider. 

As always, any time you call a health insurance company, take notes and ask for the representative’s name and a reference number for the call.

Good luck with your network gap exception request!

Bottom line: It never hurts to ask!

I had a great win for a client recently! Award-winning investigative journalist/author Marshall Allen decided to write a "Victory Story" about it. Read about it here. Contact me if I can help you with your insurance/billing issue!

Scenario: Dad had a stroke. He can’t speak. To complicate matters, this happened while he was on a business trip in another state and he is in an HMO. Daughter needs to find out information from the health insurance company about where he can go for skilled nursing/rehab care after discharge from the hospital. Daughter calls insurance company and, of course, they don’t want to speak to her because there is no authorization form on file (and to get one on file can take 2 weeks for processing). The customer service representative will speak to the daughter if her dad gets on the phone, provides his contact information, and gives verbal permission… but daughter had already told representative that HER DAD CAN’T SPEAK as a result of the stroke. 

How could this inconvenience and aggravation have been avoided? By having a release of information form completed and on file. Take the time this weekend to print out your health insurer’s “Authorization to Release Information” form, fill it out, and send it in. Then call your insurer in two weeks and make sure they received it. 

Here are links to the forms for some health insurers:
Blue Cross and Blue Shield of Illinois
United Healthcare
Aetna
Humana
Medicare

While this is not the most exciting topic, it is incredibly important and could save you some hassle in a crisis situation.

Also, a reminder that when you call your health insurer, always keep detailed notes from the call and ask for the representative’s name and the reference number for the call. This could come in handy if there’s a dispute later about what you were told.

​Holidays are often a time when we see family we may not have seen in a while. This may be even more true this year after dealing with Covid for the past 20 months. You may notice physical or cognitive declines in older family members. Be sure to take note of these changes and thoughtfully raise issues of health, safety, and living situation if it’s warranted.

While we like to think of the holidays as a time to relax and catch up, they also offer an opportunity to take care of important health and financial planning. Here are some things that are important to have put in order before there is a health crisis:

• Make sure advance directives are in place and up to date
  • It’s not enough to have the forms filled out… if your health care agent doesn’t know what you would want them to do, then your advance care planning isn’t done. It can be a difficult conversation to have, but one that is so important. If you want help facilitating this conversation, please contact me
  • Make sure everyone who needs to know where the forms are kept, knows this information. The health care agent should have a copy of the form
• Print out release of information forms from the insurance companies; this way, if there’s an emergency situation, you will already be in the system as someone approved to speak with the insurance company. Here is the form for Medicare; for private insurance companies, you can find the form in your member portal or through Google (eg, here is the form for BCBS Illinois)
• Obtain and create a list of important passwords; copies of important documents; names and contact information for doctors, estate planning attorney, accountant, financial planner, etc.
• Make a health information binder 
• Make a plan to address any concerns that have come up during the holidays

I know that sounds like a lot to do, But if and when the time comes, you’ll be happy that you’ve done all this prep work!

​Please contact me if I can help with anything.

My kids always talk about how they didn’t learn practical  stuff in school - such as how to file their taxes. This summer, I saw the perfect sign in a store: “Good thing I learned about parallelograms in school instead of how to do my taxes. That really comes in handy during parallelogram season!” I modified the sign a bit in the photo to the left.

 I wish there was a required class to learn about health insurance and Medicare! It sure would make open enrollment season a lot easier for health care consumers!

Some of the calls/emails I’ve received in the past few weeks:

• “I just found out my dad was talked into switching to a Medicare Advantage plan last year. How can we get his old Medicare supplemental insurance back ASAP?”
• “I thought my new doctor was in-network but I didn’t confirm that and he’s out-of-network and now I have a huge bill. Can you help?”
• “Medicare pays for long-term care, right?”

Answers: 

• Highly unlikely. 
• Try to negotiate a lower amount but only see an in-network doctor from now on. 
• That’s a hard no.

I can’t stress enough how important it is to take some time to learn about how your health insurance works and how Medicare works! A few tips about using your health insurance:

#1 STAY IN-NETWORK. That’s pretty clear. Know your network. Choose doctors and hospitals that are in the network. Don’t rely on the online provider directory from your health insurer’s website - those are notoriously out-of-date and filled with errors. Call your provider to confirm and call the health insurer to confirm. Take notes about who you spoke with and ask for a reference number for the call to the insurance company.

#2 Look over the plan documents and understand what’s covered, what isn’t, and what your costs are in different situations - e.g., going to immediate care vs. the emergency department.

#3. Generics can save you money on prescriptions.

#4. Make sure you understand the rules for pre-authorization. Err on the side of caution: call your health insurance company to confirm even if your provider tells you you don’t need pre-authorization or they took care of it for you.

#5. When a test or procedure is recommended, ask questions. Why do I need this? What will it cost? What information will it give you that you don’t already have? Imaging tests (e.g., MRIs, CT scans) are generally most expensive in the hospital versus an outpatient facility.

#6. For elective tests and procedures, be strategic about when you get them - before or after the new year depending on whether you have met your deductible or not.

Specific to Medicare:

#1. DO NOT switch plans - or switch from Original Medicare to Medicare Advantage - without having someone you trust look over the information. While you can switch between Original Medicare and Medicare Advantage each fall during open enrollment, you may not have “guaranteed issues rights” to get a supplemental policy at that time or at a later date. Tell everyone you know who is on Medicare not to switch plans without careful consideration and a second opinion from a family member or friend (or patient advocate!)

#2. Medicare does not pay for long-term care. Period. It will pay for UP TO 100 days in skilled nursing/rehab in specific situations. After that, you’re on your own.

#3. Medicare’s annual fall open enrollment season starts October 15th. The commercials, mailings, etc from insurance companies/agents are about to ramp up exponentially. Remember: if something sounds too good to be true, it usually is. Please do not make any changes to your Medicare without reviewing your options with someone you trust - some changes have lifetime ramifications!

There’s so much to know about Medicare. I have a great presentation which helps people to understand their Medicare coverage. Contact me to schedule this presentation for your organization or even for a group of your friends.

Bottom line: We aren’t taught about health insurance in school or anywhere else. It’s up to us to learn how the system works. But you still need to understand parallelograms to pass geometry.

Has ANYONE ever looked at an EOB (Explanation of Benefits) and thought “oh, this is easy to understand?” I bet very few people would say that. EOBs are definitely not written in plain language. There are codes, there are a bunch of numbers in different categories, sometimes the numbers do not even add up correctly. When you try to compare it to the billing statement from your health care provider, the terms used aren’t identical and the billing statement generally has very limited detail. How do you know if your claim was processed correctly and if you are paying the right amount?

Estimates are that up to 80% of medical bills have an error. Therefore, it’s important to look at your bills and your EOBs and make sure that everything is correct.

Also, know that an EOB is NOT a bill. Wait to receive a bill from your provider before making any payment. But be sure to look at the EOB before paying the bill.

Here’s an example of an EOB (with identifying information blacked out):

1. Make sure the patient name, member ID, and group number are correct. You may think I’m kidding, but these mistakes do happen.
2. Provider - the name of the hospital or clinician who provided the service.
3. Service description - well, isn’t “Medical Visit” descriptive! Especially if you had multiple “Medical Visits” that month. You’ll need to double-check that anything listed under service description matches up with what your provider is billing you for.
4. Amount billed - this is the amount that the provider is charging. As journalist Marshall Allen writes in his book, “Never Pay the First Bill,” “this is like the manufacturer’s suggested retail price on a car. No one is expected to pay the amount, and it can be whatever charge they want. Often, it’s many times more than what they would accept for the service, because the insurance company wants to be able to say it got the patient a discount.”
5. Discounts and reductions - There is often a footnoted explanation here. This website lists almost 300 codes that could be on an EOB! Basically, this amount is a contractually agreed upon discount between the provider and insurer. For a detailed, and appropriately cynical and sarcastic take on this, see this link.
6. Amount covered (allowed) - healthcare.gov defines this as “The maximum amount a plan will pay for a covered health care service. May also be called “eligible expense,” “payment allowance,” or “negotiated rate.’”
7. Your Responsibility section - this lists whether you owe a deductible, copay, coinsurance and/or the amount not covered (see my previous blog for definitions). In this example, the patient has a $50 co-pay for a specialist visit.
8. Summary - Plan Provisions  & Your Responsibility- restates the above information in a different format. A key number that we all zero in on is the amount that “You may have to pay your provider.”

This was a pretty simple EOB - just one service listed, no denial codes. You can see that the one below is more complicated and also has a list of vague service descriptions (eg, “drugs” listed 6 times but no detail on the type of drug); this is why it’s helpful to compare your EOB with an itemized bill from your provider to make sure you are only being billed for services you received. Some of the patient’s responsibility falls under deductible/copay while some falls under coinsurance; this is because coinsurance kicks in after the deductible is met for the year (based on all claims for the year, not only the current EOB).

Make sense??? 

​Bottom line: Compare your EOB and billing statements; request an itemized billing statement from your provider. If you have questions, call the customer service number listed on the EOB or the back of your health insurance card. I’m happy to help as well! 

A few months ago, my friend’s daughter, a freshman in college, had a health scare. Fortunately, everything turned out okay! But my friend hadn’t had her daughter fill out any of the necessary forms to allow the doctor and hospital to release information to her or even to speak to her about her daughter’s medical concerns. Trying to get a busy (and uninterested) college student to fill out the necessary forms while in another state in the middle of a semester was not quick, easy, or painless. 

There are privacy laws (HIPAA) that restrict what a health care provider can share about any adult 18 years or older. Yes, this applies even if your adult child is still on your health insurance plan. Please refer to this article with advice about what forms you should have your 18+ year-olds sign. You can complete these forms on your own or meet with an estate planning attorney. (Special thanks to Emily Rozwadowski of Spencer & Rozwadowski, LLP for reviewing this information.)

Briefly, the four important documents are:

1. Health Care Power of Attorney - allows you to designate someone to serve as a your proxy or agent in case you are unable to make medical decisions on your own (Illinois form)
2. HIPAA Authorization - a document that allows health care providers (and others) to share specific health information with people who you designate to receive that information (sample form from the American Bar Association)
3. Durable Power of Attorney/Power of Attorney for Property - allows you to designate someone to act on your behalf for financial matters
4. FERPA Release (Family Educational Rights and Privacy Act) - permission to access educational records (more info and model forms here)

If your adult child is attending college in another state, it may be safest to fill out forms for each state. Some colleges have their own forms as well (e.g., the University of Illinois has this authorization to release confidential health information form); this is something worth asking about at parent orientation.

Once you’ve filled out the forms, keep them in a secure place. Also, be sure to scan them so you can easily access them from your phone as well as from your child’s phone.

So, while you’re checking towels, sheets, comforter, etc off of your college packing/to do list this summer, please add “fill out important forms!"