By Dennis Botts, MSW
These tips are from the experience of those who have lived with chronic illnesses. I have gathered this information from patients, their families and caregivers, health care providers, and my own experience as a diabetic, organ transplant recipient, and cancer survivor. As with any information, please be careful and make major decisions with the advice of experts who are familiar with your situation.
The most common questions about the practical issues of chronic illness usually have to do with the management of finances and coordination of medical care. There are good and better ways to understand and approach both.
It will not take people very long after diagnosis to discover that the system of using insurance and getting medical care has changed. What treatment, where, which Physician you can see, and medications allowed is a process many will find a frustrating process. It cost less to use certain hospitals, physicians and pharmacies because insurance is contracted with those providers. These days you find yourself a consumer looking to make the best deal for health care. It’s not automatic. It’s less convenient, but a practical matter of cost saving for everyone. We will be talking more about what you can do to become a good consumer of health care and save on costs.
Most of the time generic medications, second opinions, and even delays in treatment are required and these matters are worked out with your physician or pharmacist and the insurance carrier. You will hear terms like “prior authorization” (your doctor verifying his order as necessary) and “exceeds plans limits” (preset limits on the number of pills or refills or services and requires additional approval from the insurance). It’s not your brand of insurance or the people you are dealing with on the phone that is the problem, it’s the way everyone’s’ health care works now.
Try not to become overwhelmed. The first step in addressing financial matters is to be calm and patient; there is plenty of room for mistakes, confusion and frustration. Look at your budget and try to find ways to be prepared for extra costs. Know your deductibles and co pays, and ask your insurance carrier to review your policy with you. Hospitals and physicians have financial counselors who can explain Medicare, Medicaid, or your insurance coverage, and payment options. Pharmacies will check with your insurance and determine your coverage limits before filling your prescription. This is a phone call that can save on frustration and extra trips to the pharmacy.
Secondly, keeping records. It helps greatly to get organized and create folders for keeping up with bills, and medical records. Using a personal computer is really great, and most pharmacies keep medication records for you, available on the internet. You will get statements from insurance called EOB, (explanation of benefits; this is your receipt of their payments).
You should keep these for at least 3 years for tax purposes. (Keep medical records indefinitely). Always keep a copy of lab reports and surgery reports. Bring them with you to see physicians, when traveling, or visits to the emergency room. The med alert bracelet is a great idea. Go to www.medalert.com for details. Also, pharmacies and insurance companies how have a record keeping service to help you organize this information. Not a records person? Ask someone who is, to lend a hand. It gives them a real way of helping out.
Thirdly, be careful how you pay your bills. Many people enjoy the convenience of credit cards to pay medical bills, because it’s easy, everyone accepts them, and payment is deferred. It is also a back door to an expensive loan should you not make payments regularly.
Many people have fallen into what is called, “universal default” from late or no payments to credit cards. Universal default means no limits on how high fees and interests can go, and with new bankruptcy laws, there is garnishment of wages, seizure of assets as well as never ending telephone harassment. In addition, your credit will be ruined. We will cover others options with health care debts.
The fourth tip of saving on health costs is to become involved in your wellness. Small changes on a daily basis have a tremendous impact on how you feel and how much you will spend on health care. Everyone knows that eating healthier, quitting smoking, and some exercise routines, at least walking and stretching is good for us. Sometimes it is better to skip the handicapped parking and give yourself a nice walk to the store.
Keeping up with regular check ups is a healthy thing to do also. Your physician is not only monitoring current problems but also screening for diseases like heart disease and cancer, and saving your life with early detection. Everyone has to have a primary care physician, particularly if living with chronic illnesses. You cannot manage your health at walk in clinics, the emergency room, or on Aunt Molly’s advice. People who visit their physician regularly will have less illness, and fewer hospitalizations.
Getting the almost free to everyone annual flu shots, pneumonia vaccines, and free cancer screenings in your community is very good for your health and your finances.
Medicare and Medicaid, as well as some employers and many private insurance carriers will provide or pay the cost of these vaccines and tests. A smart consumer takes advantage of this benefit.
1. It is best to always seek assistance from providers before going into expensive debt. Physicians, hospitals, and clinics will often offer low or no interest payment plans if you ask for assistance. Some offer programs that reduce or waive costs after insurance, if you are in great financial distress and meet their eligibility criteria. But you must ask and apply with their financial office. They understand the devastation of illness on finances and you would not be the first to need special consideration.
2. Always be careful of making major financial decisions when emotions are high. The shock of diagnosis is not a good time to make a decision. Sometimes people will think it is best to stop employment, retire early, sell their home, and even cash in retirement savings. These decisions are often unnecessary and can cause the very financial hardships you are trying to avoid.
3. Everyone has a different outcome and the future is never that predictable. Also, be careful of annuities and other retirement plans known as “a guaranteed income from insurance companies”. It is common for people with chronic illness to worry about future income and be approached about special retirement plans. Careful planning and expert advice are always available and often free. Your insurance company, bank, or financial institution usually has financial planners available to help you consider choices for your financial security.
Other unexpected costs, like uncovered supplies, transportation costs, or the cost of treatments out of town can be very expensive on a limited budget. There are special programs for assistance, some you may already have and others you will have to seek. Some catastrophic or indemnity policies are already attached to your health policy. They often pay for transportation of the patient, and some pay for the hotel costs and travel costs of the patient and a family member. Cancer and catastrophic policies can really help with the extra costs of being ill.
Airlines offer compassionate discount fares for patients and families for hospitalized patients. And, frequent flyer miles can be gifted to a person and family in need. Note, however, the transportation insurance purchased with a ticket is usually void if you are traveling for the purpose of medical appointments, or you have a pre-existing condition.
Other air travel for treatment includes “Angel Flights”, private air travel donated by executives with private aircraft. Please contact the Hospitals’ Social Work Department for more information.
Hotels near medical centers usually offer discount fares for patients and families and many have special services with shuttle and other services. Hospital Social Workers will have a list and other helpful information about these services.
Just because its medical related or doctor ordered, does not mean IRS will accept it as a deduction, and there are percentage limits based on your income. You can claim insurance premiums. You cannot claim a swimming pool for your bad back, so check with your tax expert and keep good records, especially if there are expenses for medical travel and supplies.
Medications are sometimes ordered on a trial basis to see if they are helpful and if you can tolerate them. Asking for samples from the physician is a good way to get started with a medication you may only take for a few days.
Discount cards usually offer little or no savings, but if they are free you may find a small savings with a particular pharmacy. They are no substitute for insurance.
Generics are great and often at a discount, sometimes as little as a few dollars a prescription, with or without insurance coverage. However, there are times generics are not appropriate for your situation, and your Physician will be asked by your insurance to justify the reason you must have the brand medicine. This could delay your prescriptions, just as it would if the prescription was for an amount not approved by your carrier. Everyone will encounter restrictions on some of their prescriptions; it is not a personal attack on you, it’s just the business end of health care. Be patient, your doctor, pharmacist, and insurance will come up with the right combination for you.
Formulary: To make sure your physician prescribes what your insurance covers bring your list of medications (known as “formulary”) with you on your doctor appointments. Your formulary is usually found with your policy or listed on the internet. The will save time, money, and confusion at the pharmacy. You want to have prescriptions your insurance has listed on their formulary, otherwise you are charged full price, or the prescription has to be changed.
If your prescription is not on the formulary, the same medication is usually available under a different name and your physician can prescribe that medication. If still not on the list, you can ask your insurance carrier for an exception and have your medication covered. The pharmacist is helpful with this action. Your physician and pharmacist know about this process, but it is up to you to keep your physician up to date on your insurance and what medications are covered. The formulary changes often so you need up-to-date lists..
Using mail order will often get you a substantial discount, as much as 20% on orders for a ninety day supply. It is important however, to still have prescriptions to get your medications locally should there be a delay in mail delivery.
If you are eligible, the pharmaceutical companies have free medication programs, but the application process is thorough and time consuming for you and your physician. It can sometimes take several weeks before approval and delivery. You may need some samples to see you through this process. You may not qualify for these programs if you are eligible for the new Medicare Part D insurance, unless you are in the coverage gap or “donut hole” and cannot afford your medications. Ask your physician, pharmacist or call The Partnership for Prescriptions Assistance at 1-888-4PPA-NOW (1-888-477-2669).
The most recent comprehensive medication program has been Medicare Part D. There is an Enrollment period and a coverage gap, it is the biggest entitlement since Medicare and people can choose plans with monthly premiums of $30 to $100 depending on where you live. You would know this insurance is well worth the costs if you have bought your own medications lately. You will need to apply through insurance companies offering the plan; a list is available from Social Security or on line at www.medicare.gov.
Always have the medications in their original prescription bottle or a prescription for that medication handy, especially if it’s a narcotic. Some states prohibit diabetics from having needles without a prescription. All sizes of liquid medications are accepted by airline security, if identifiable, and in full view
And if you are traveling abroad, please remember that your Medicare and Medicaid and many private insurance carriers will not provide coverage outside the United States. You can buy special travel health insurance from a travel agent or transportation carrier, but read carefully about pre existing conditions. Remember, travel insurance is not the same as travel health insurance.
Can I get insurance after being diagnosed? Yes under certain conditions:
- If you continue to be employed, or
- If you return to work full time for a certain length of time, or
- You become the spouse of someone with a group policy, or
- You complete the pre existing condition clause of some policies, especially indemnity policies (pays directly to you for per day or per treatment or procedure. Usually offered through organizations, professional groups, or clubs like AARP, your bank.)
A source of income from insurance is “viaticus or “accelerated benefits”, a part of most life insurance policies. You actually sell your policy through a broker for a discounted amount. Many people find this benefit helpful if they have pressing financial needs now, like children’s college, paying off mortgage, catching up debts, traveling, etc. Some viaticus settlements are valued at tens of thousands to hundreds of thousands of dollars, depending on the value of your insurance. Also, income from viaticus or accelerated benefits is not taxable. Your insurance agent, Social Worker, and health care providers can direct you to more information about this benefit.
Whether private insurance or Medicare and Medicaid, you have rights to appeal any decision you feel is unjust or unfair. Do not be afraid of the paperwork, ask for assistance, but remember, appeals are time limited. Every bill or correspondence with all carriers has information about appealing their decision, or you can contact your carrier for the procedure. AARP has assistance information and contact numbers to affect an appeal.
You may have to pay for your medication or services until the appeal is complete, and then apply for reimbursement.
(Some examples for appeal: your prescription may be for a higher than normal dose and is rejected, or a new procedure is considered as experimental or unnecessary to the insurance, or treatment at another facility is not approved.)