Nov 282011

As you are considering your Medicare enrollment be sure and consider the $0 premium Medicare Part C plans that are available.  Now, this may not be for everyone depending on your health needs, but several companies offer this type of plan to those in a specific income bracket (don’t worry the majority of medicare subscribers fall into this bracket.)

The way this works is the Medicare part C plan replaces Medicare A, B, & if you choose D.  So the monthly premium that you pay for Medicare, is what pays for this insurance plan.  So while you would continue to pay your monthly Medicare premium you would not have to pay any additional premium.  I know this was a huge savings factor for my grandparents.

The easiest way to find these plans is by using the Medicare Plan research tool at

Additionally two options I can think of available in the NW United States are AARP Secure Horizons and/or Healthnet Violet Option 2 PPO.

Remember you need to weigh the benefits of no premium against the cost of co-pays, deductibles, etc to make sure it’s going to work for you.


Nov 252011

The Medicare enrollment deadline is quickly approaching and there have been many television commercials and newspaper articles discussing the various Medicare prescription plans.  However, all of them focus on the premiums and low tier one co-payments, but they all fail to explain some important factors.


Different plans have different pharmacy networks.  Generally you will need to use a network pharmacy to receive benefits; so you will want to make sure that there is a network pharmacy near your home.


This is where the tricky part comes in.  Different insurance companies assign each drug to a tier.  What tier it is in dictates how much of a co-pay you will have to pay when you pick up your prescription.  As for what medications are assigned to what tiers–well it varies plan to plan.

Therefore, to really know if a prescription plan is right for you, you need to know what tiers your prescriptions fall under.

This can be accomplished two ways.  1. Use the benefit comparison tool at 2. Contact each insurance plan you are considering.  You could either call them to request the pharmacy information or go to their website and view their pharmacy information.

You will need to know what tier your medication is in and what the co-pay for that tier is.

Co-pays within Tiers

Often the different tiers have a gradual price increase as you go up in tiers, however, some insurance plans have sharp jumps in price tier to tier.  For example a three tier (tier one is abbreviated T1 and so on) plan may read as: T1 = $15, t2=$35, and T3=$70.  Those are steep price jumps.  However, other plans could read like this: T1=$10, T2=$20, T3=$35, T4=$45, T5=50%

So understanding how many tiers a plan offers, where your medication fits into those tiers, and what the co-payment is for each tier offered is the best way to find out how much money you are going to spend on prescription drugs in addition to any monthly premiums that you pay.




Nov 232011

Medicare is divided into multiple letters that represent different Medicare plans.  The main plans that you hear about are Medicare part A, B, C, &D.

Medicare part A covers hospital expenses.

Medicare part B covers doctor office visits

Medicare part C, is actually a managed care replacement plan for Medicare Parts A, B, & D and are offered through private companies.  If you have a Medicare Part C plan, you would give your doctor your health insurance card and not your red, white, and blue, Medicare card.

Medicare Part D is prescription coverage.

If you have Medicare Part A and/or B then you may also purchase Medigap, supplemental insurance to help cover costs that Medicare does not cover.  Medigap insurance may also help pay deductibles, co-pays, and or co-insurance.

This post is meant as a very high level overview; details will be available in further posts or in tutorials/eBooks, etc available for purchase.

Nov 162011

What your doctor bills is not always what your insurance company will pay.  The allowable rate/expense that the insurance company will pay is based on two things: contract and/or usual and customary rates.


If you are seeing an in network provider then your insurance company has a contract with them for how much they will be paid. The price in the contract agreement is often the allowable rate for these instances.

One key-note to remember is that just because your provider is in network for one service does not mean they are in network for all services.  For example a mental health counselor may be contracted for individual counseling but not contracted for psychological testing.


Usual and Customary Rates (UCR)

If your provider does not have a contracted price then your insurance company may use a UCR rate.  These rates are often calculated as a percentage of the federally allowed Medicare rate.

However, other insurance companies may have a set percentage for out of network providers.  For example they may pay 50% of billed charges.  However, they may also express it as 50% of UCR Rates, so be sure and consult your plan document to know which one your insurance plan uses.

In these instances the UCR rate or the percentage allowed of billed charges will be the allowed rate that your insurance company will consider paying.  If there is no contract in place then you will be responsible for paying your provider in full, after the insurance has made their payments.

For both of the above instances it is important to note that your insurance company generally won’t pay 100% of the allowable rate unless you have met an out-of-pocket maximum.  There are generally deductibles, co-payments, and/or co-insurances that you will be responsible for paying.


Nov 092011

You and I both tend to think that if we have health insurance then our insurance company should pay for the health services we receive.  Unfortunately, we are wrong.  Each insurance plan will have limits called Exclusions.

Types of Coverage Exclusions

Companies can limit the types of health treatment that they cover. For example an HMO plan does not cover out of network providers, so if you saw an out of network provider your claim would probably be denied payment.


Treatment Exclusions

These types of exclusions cover a wide range of topics from level of care to following your plan requirements.  For example, some health plans will not cover residential levels of care as treatment.

Of course there is also the all-covering: medical necessity.  If the doctors that work for your insurance company feel that you could have been treated differently then they may deny your claims payment.  However, remember you have appeal rights.

Another primary exclusion under this type is if you or your provider did not follow your insurance plan requirements.  For example if you were required to get an authorization before services but you didn’t, then the claim may be denied.

Experimental and Investigational treatments (as determined by your insurance company) will not be covered.  This is very common and often applied to ABA therapy for Autism.  While the laws surrounding Autism treatment are changing, there are still some loopholes that insurance companies are using to deny this and classifying it as experimental is one of them.

Prescription, Vision, and Dental Exclusions

Essentially all parts of your insurance coverage may have exclusions.  Sometimes an insurance plan will refuse to cover a specific medication because they feel there are others available or they deem it experimental.

Many vision plans exclude voluntary treatments, like lasik surgery.

Dental plans will only cover certain amounts of treatments before excluding them as not medically necessary.

The point here is to know what is excluded from your plan.  If possible, you should always consult each section of your Plan Documents (certificate of coverage, member handbook, summary plan descriptions, plan document, etc) for their own exclusions before receiving treatment.



Nov 022011

The EOB, which stands for Explanation of Benefit is the statement that your insurance company sends you to show what was and was not covered by your insurance. Explanation of Benefits can be broken down into several parts.

1. Provider, Patient, and  Date of Service: I know this seems obvious, but make sure that the information is what you expect it to be.  If you think it’s not call your provider first to verify and request that they contact the insurance company.

2. Services: this area is a short description of what you had done.  This may include CPT and/or ICD-9 diagnostic coding.  The main reason you would need this information is if you felt your claim did not pay correctly and you wanted to file an appeal.  Also make sure you are being billed for the service you actually received.

3. Billed Amount: This is the actual billed charges from your provider.

4. The breakdown of what was or was not paid:  This is expressed differently depending on your insurance company; however, the information used is still the same.  After the billed amount will be information regarding what amount your insurance company allowed.  This number will have to do with whether you saw a network provider and therefore received a discount or it may be based on usual and customary rates, depending on your plan.

Once the price that the insurance company is willing to pay (the allowed amount) is determined, next comes deductibles, co-payments, and co-insurance.  The co-insurance may be expressed as “you pay this %” and “insurance pays this %” sections.  This is your responsibility to pay and the actual amounts and terms will depend on your health insurance plan.  These will be subtracted from the allowed amount.

5. Next will the amount that the insurance actually pays.  This may or may not leave a zero balance.  Often you will be responsible for co-payments, deductibles, and/or co-insurance.  However, if you saw a provider or had a procedure that is not covered by your insurance then you may be responsible for the entire bill.

6. Remark Codes: If you have to pay any amount the remark code at the bottom of the EOB should explain why you are having to pay it. For example, remark code D1: patient pays co-payments and deductibles, or something to that effect.  The one thing you have to understand is that these remark codes can be wrong–especially when a claim is denied payment.  In the cases where you think it is wrong you will need to contact your insurance company or if they have online access to your information, go online and compare the EOB information with your benefit plan information.  Remember, you always have the right to appeal.




Oct 242011

A referral to an authorization is a slippery slope.  First let’s define each term.

Referral is your primary doctor saying you need to see this specialist.  They sometimes give you a piece of paper or they will call the specialist for you.


Authorization is when you or your doctor calls your insurance company and gets permission to perform the requested treatment.


How do you know which one you need?  Read your plan documents and they should tell you; however, this is where that slippery slope comes in.  It’s all down to interpretation.

The silent factor:

Sometimes your benefit will not say either way.  It just gives you your benefit and you are left wondering if you need an authorization.  Tip–call your insurance company and ask.

The two places dilemma:

Most people look for the grid like pages that state what the services is, what their co-pay is and what their insurance will cover.  Often this benefit will not mention prior authorization, but somewhere in the pages before or after that grid will be an explanation of what needs authorization and what doesn’t.  So don’t just rely on the grid.


The specialist loophole:

So you have read your benefits and it just says, same as medical or treat like a physician visit so you figure you are safe and you do not need an authorization or referral.  Wrong.  Depending on your doctor type you will need to see if referrals or authorizations are needed to see a specialist.  Now what you would think of as a specialist compared to what your insurance company thinks is a specialist is probably going to be very different.  So read carefully, and a safe assumption is that if it’s not a general doctor who you would go to for the flu, then call and get an authorization from your insurance company, or at least call and ask.

The It said referral but I was denied for no authorization situation:

Here is the core issue here.  Your insurance claims department does not know what they are doing or your doctor’s biller does not know what they are doing.  What happens is that the claims department will deny because they use referral and authorization interchangeably even though they are two different things.  The other issue is that your specialist will bill and not send a copy of your primary doctor’s referral with his or her bills.  Therefore you insurance company does not know that the referral exists and denies.  The solution is that if your benefit says you need a referral, get one, but then call your insurance company and ask for authorization too.  If they say it’s not needed then you at least tried.


Whenever you talk to your insurance company have a notepad and pen handy.

Record the following for any conversation that you have:

The date and time.

The phone number you called.

The first name, last initial and location of the person you are talking to .  This could be a state in the U.S. or a city in a different country.  Not everyone will want to give you this information.  If they refuse, ask for their manager.


Oct 172011

The majority of health insurance plans have deductibles.  This is an amount of money that you have to pay before your insurance benefit kicks in.  The thing you have to look out for when reading your plan documents is how many different deductibles you have.

Individual deductibles apply to each individual on the plan.  So, if you have a $1000 individual deductible before your insurance will pay and you have four members of your family on the plan then each member will have to reach the $1000 deductible before the plan kicks in.  So you will need to plan for $4000 if you think all of your family members will need that much medical care.

Family Deductibles can either help you or make no difference whatsoever.  Some plans will say that if you’ve met the family deductible then coverage for everyone kicks in.  However, often the “family” deductible just equals the individual deductibles added together.  Sometimes the family deductible will be less than the combined individual deductible but it’s rare.

For example

Individual deductible = $1000

Family of four family deductible = $4000


Rarely will you see:

Individual deductible = $1000

Family of four family deductible = $3000


As you all know, some insurance companies have really crappy plans.  For example my Mom’s insurance plan has the individual deductible mentioned above (but hers is $2500) and it has a Prescription deductible.  This means that she has to pay $1000 out-of-pocket before her insurance will pay for any of her prescriptions.  This is on top of her individual deductible.

The last type of deductible is the differences between In network and Out of network.  Most insurance companies have a higher deductible if you are using an out-of-network provider, but any money you put out counts toward that deductible.

For example you pay $50 it goes toward your in network deductible of $1000, but it also gets counted toward your out of network deductible of $2000.  It’s like a buy one get one free.

However, other insurance policies don’t work like that.  They have two separate deductibles.  One for in network and one for out of network.  In that example the $50 you paid to an in network provider only goes to the in network deductible.  If you have to go see an out of network provider then you have to start all over from $0 to meet the out of network deductible.

It’s important to read your plan documents so you understand how many deductibles you have and how they are applied.

Oct 112011

Medicare open enrollment used to start in November; however, with recent law changes Medicare open enrollment now begins October 15th and runs to December 7th.  It is always best to enroll or renew as early as possible to prevent any delay in coverage.

A quick review of Medicare:

Medicare part A covers hospital costs and some home health.

Medicare part B covers doctor office visits and some home health.

Medicare part C is also known as a Medicare Advantage Plan or a Medicare Replacement plan. This plan replaces your original Medicare plan, which is just another way of saying: If you have plan C then you do not qualify for plan A&B.    However, Part C covers hospital, doctor offices, home health, and for an additional premium some plans offer vision and dental.  They also offer prescription coverage.

Medicare part D is only prescription coverage.

Medigap is also known as Medicare supplemental insurance.  There are multiple types of policies, so be sure you get the right one for you.  A Medigap policy can only purchased if you have Medicare A and/or B.  You cannot buy a Medigap policy if you have Medicare part C.