2011 > September

Monthly Archives: September 2011

Simplee member offers tips for better dental care

Whenever we are tell people about Simplee, we are struck by how everyone seems to have some story about getting overcharged by a provider, rejected by an insurance company, and generally bumped around in a system that is decidedly customer unfriendly. 

Today’s story comes from Simplee user David of Sunnyvale, CA:

We all know that planning can be very effective. It is especially important when it comes to dental insurance. Since most dental insurance (including mine) has an annual cap, making sure this cap is used in the most effective way could save you big bucks.  I always heard stories from friends about the thousands of dollars they paid out of pocket for their dental treatment, and now I know why.

About 2 years ago my dentist told me I needed a root canal and a crown.  These two treatments are very expensive, with costs ranging from $1,000 to $1,500 each.  Put these two together and they can easily surpass the cap on the annual dental insurance allocation—mine, for example, was $2,000.  Once your cap is met you need to start paying for treatments out of pocket.  So since it has been the end of the year, I scheduled the root canal right away and the crown for the beginning of the year.  The expenses fell into two different years so I stayed below my cap.  I still had to pay the deductible of the treatment but I probably saved hundreds or even thousands of dollars.

A few lessons I learned from this:

1) Track your dental spending for each family member

2) Plan ahead and be aware of your annual cap

3) Make sure that for major treatments, you submit a pre-authorization to your insurance so you know exactly how much you will pay for the service before you start with the treatment

Thanks for sharing again, David


Health Savings Plans: Making Sense of HSAs, HRAs, and FSAs

This post also ran on the Mint.com blog.

Did you eyes glaze over a little when you read that headline?  Well, sign up for a health care plan these days, individual or employer-sponsored, and that is the kind of alphabet soup you might have to wade through. More and more companies are looking to cut costs by offering high-deductible health plans (HDHP), also known in the industry as consumer-driven health plans (CDHP).  These plans feature lower premiums in exchange for a higher deductible—the part of care you pay for out of pocket before insurance kicks in.  They are often paired with some sort of savings account that allows you or your employer to set aside money to cover your expenses.

These savings plans can make a lot of sense from a tax-savings standpoint.  Funds can be set aside pre-tax or, if they are contributed later, deducted from taxes, so in effect any time you use the money to pay for your medical costs it is like you are getting a discount equivalent to your tax level.  That’s why it could be a smart move to set one up even if your employer doesn’t offer it as a benefit.

So which plan makes sense for you (if you have a choice)?  Let’s decode some of the TLA (three-letter acronyms):

HSA: Health Savings Account

Health savings accounts (HSAs) are a popular employee benefit: over 40% of companies offered an HSA in 2011, with 12% more expected to do so in 2012.

How it works: HSAs allow you to set a portion of each paycheck aside into an account that accrues interest like an IRA.  Employers or other people can also contribute to the account.

Who can have an HSA: Only people covered by a high-deductible health insurance plan, defined as a deductible of $1,200 for a family or $2,400 for a family.  If your employer doesn’t offer an HSA you can open one up on your own, so these are ideal for the self-employed.

What it covers: Qualifying medical expenses such as deductibles and co-payments.

Carry-over and portability: You own the funds that go into an HSA, and anything that you don’t use carries over from year to year.  If you leave your job you can take the funds with you.

HRA: Health reimbursement account

While an HSA is like an IRA in that it’s an investment owned by an individual, a health reimbursement account (HRA) is a benefit offered by an employer that ends when the employment does.

How it works: Only employers may offer HRAs, and only they may put money into it.  The money is not considered income, which means that it is not subject to income or payroll taxes.

Who can have an HRA: An HRA can be used with any kind of health plan.  You cannot open up an HRA on your own.

What it covers: An HRA is the only type of plan that can be used to pay insurance premiums as well as medical expenses.

Carry-over and portability: The funds in your HRA belong to your employer, and when you leave your job any funds in the account stay with them.  Your funds might roll over year-to-year or they might not; that is up the employer.

FSA: Flexible savings account

Flexible savings accounts are like HRAs in that they are employee benefits, and employees can only use the funds as long as they are employed.

How it works: Unlike an HRA where employers fund the account, with an FSA the employee funds the account with a portion of each paycheck.  The money is set aside pre-tax so you get tax savings, but it does not accrue interest.

Who can have an FSA: An FSA can be used with any kind of health plan, but you cannot open up an FSA on your own.

What it covers: An FSA may only be used on qualified medical or dental expenses (not premiums).  As of 2011 you cannot use FSA funds on OTC medicines without a doctor’s prescription.  In 2013, there will be a cap of $2,500 on the total funds in an FSA.

Carry-over and portability: An FSA is a “use it or lose it” plan; any unused funds in the account at the plan’s year-end are forfeited back to your company.  You also lose access to the funds at the end of your employment.

You may even come across a couple of other options, such as an HIA (health incentive account) or an RRA (retirement reimbursement account).  Whatever you encounter, just look at how the plan gets funded, what it covers, and whether you get to roll over or keep the funds.  Track deposits and expenditures carefully, keep receipts for tax purposes, and enjoy your savings!



How To Appeal a Denied Health Insurance Claim

Anyone who has ever submitted more than a very basic claim to their health insurance company has probably dealt with having a claim denied.  It can be a very frustrating experience, and sometimes it feels like the insurance company is trying to wear you down until you just give up.  But the Affordable Care Act, aka “Obamacare,” has several provisions that can help by regulating how insurance companies must deal with appeals.

Let’s say you received a bill for your MRI when you know your plan covers them. Or your plan requires prior approval before a hospital stay but they deny your doctor’s request even though you believe it is medically necessary.  Whereas in the past your appeal would be handled differently depending on your plan’s rules, there is now a standardized appeals process that plans must follow.

If you joined your health plan after March 23, 2010, these rights apply to you. For plans created on or before March 23, 2010 (known as “grandfathered plans”), you may not have the same rights. 

Here’s what happens:

If your plan decided not to cover or authorize a service, you have the right to request an internal appeal: the plan must review their decision and provide you with a response within

  • 72  hours for urgent care claims
  • 30 days for non-urgent care claims
  • 60 days for services you have not yet received

Starting January 1, 2012, if your plan denies your appeal, you can request an independent external review. If this decision is made in your favor, the plan must cover the services. Some states have already created a process for external reviews, so you may not have to wait until 2012.

Also, some plans may have additional levels of internal review before you can ask for an external review, though the entire process must occur within the timelines above. Check with your state’s Department of Insurance or with the plan for specific rules.

Is an appeal worth your time? 

It just might be. A study by the Government Accounting Office found that anywhere from 39% to 59% of internal health plan appeals filed are ruled in the patient’s favor. And about 40% of external reviews go in the patient’s favor (http://www.gao.gov/products/GAO-11-268)).

For help with appeals, some states offer Consumer Assistance Programs. Look for yours at http://www.healthcare.gov/law/provisions/cap/index.html.

Simplee will notify you when you have claims that have been denied, and also provides you information you can use to contact your insurer to begin the appeals process.  To look at the details of individual claims, click on them in the “Clams & Bills” tab to see the detail.  Insurer and provider contact information is in the right sidebar.



Why Should I Track My Medical Bills?

Let’s say you decide to rent an apartment. You don’t know all the details in the lease and the landlord calls you on a regular basis to say there’s another expense…Would you please send a check (for some amount that sounds random)? Something just doesn’t feel right here…

Yet many of us are like that with our health care. It’s understandable—who can really decipher all the documents and sort through all the mail?

But it’s important to understand the basics of your health plan and to track your bills for several reasons. A little time could save you money later on. Here’s why.

Billing mistakes happen 

Anywhere from 30 to 40% of all medical bills contain errors of some type, according to health finance expert Stephen Parente at the University of Minnesota. Some claim the figure is even higher. These errors can include things like upcoding (attaching a more expensive billing code to the service you received so that you are charged for a more), charging more than once for the same service, or breaking a service down into separate parts and charging for each of those (like the gloves and tools used during a surgery). There are many tips for spotting these errors, but the place to start is tracking and reviewing each bill as it comes.  Check your claims detail in Simplee to see your provider charges explained in simple language.

Multiple bills

Medical bills are hardly straight-forward, so you can end up paying more than need to. It’s common to receive multiple pieces of mail related to a single medical service. The first is often an Explanation of Benefits (EoB). You know, the letter that looks like a bill but says on the top “This is not a bill.” An EoB is just a notification from your health plan that they received a bill from your doctor and explains what they plan to pay. Following an EoB, you can expect a bill from your doctor or provider. Sometimes, multiple bills are sent for the same item, so it can be confusing to determine whether you’ve paid one or not. A good way to track these is by the date of service. You may even want to keep track of the date of your medical appointments so that you can easily match these up.  And of course, you can also track things in the Simplee dashboard, which combines information from your provider and your insurance company in one place.

Tax breaks

 If your annual medical expenses exceed 7.5% of your adjusted gross income, you can deduct them from your taxes. This includes pretty much anything that is medically necessary, such as: insurance premiums (though only a portion), co-pays and coinsurance, prescription drugs, home care, acupuncture, mental health, dental treatment, glasses, and medical supplies.

Late fees

This is an obvious one. Late payments come with a late fee, so don’t put yourself there if you don’t need to. If you are unable to pay a bill right away, contact the hospital or provider. Many offer payment plans or will negotiate a discount.

Understand your spending

Finally, it’s good to know when you meet your plan’s deductible or out-of-pocket maximum. This information can help you see when you can expect your plan to pay, when you’re free from your coinsurance (whew!), how much you are spending, and how well your health plan is working for you.  Here is another area where Simplee is a big help– your deductible is tracked automatically, and you’ll get an email when it is met.

Tracking medical bills isn’t fun, but Simplee makes it a lot easier.  If you’ve been avoiding tracking your expenses, now is the time to jump in!


Struggling With Bills? Visit the Patient Access Network Foundation

We often cite the statistic that out-of-pocket health care costs have gone up 50% in the past five years.  While this sounds bad enough all on its own, when you set it against the relative stagnation in wages over the same time period and the high unemployment we have seen the past few years, it’s a sure bet that there are a lot of people out there struggling to pay their medical bills.  Indeed, a recent study found that 20% of people in financial crisis counseling said they were there because of medical debt.  And although there are 50 million Americans with no health insurance, the financially distressed are not all from their ranks: another recent study found that people with insurance were just as likely to suffer from medical debt.

At Simplee our goal is to give people better insight into and control over their medical bills.  But sometimes what it comes down to is that there isn’t just enough money to pay.  We have been fortunate as we’ve grown Simplee to encounter several organizations that aim to help people who need assistance in paying their medical bills.  One of these is GiveForward, which we wrote about here, and another is the Patient Access Network Foundation (PANF).  While GiveForward is a crowdfunding site that allows people to easily create fundraising campaigns for family or friends, PANF is a non-profit that directly provides financial assistance.  PANF helps to cover the copayments or co-insurance on medications for people suffering from chronic conditions, the burden of which can often be devastating:

Despite having to seek treatment and manage her condition, Michelle continued to lead a busy lifestyle and pursue a successful career. She got married, and worked for a major television network in the Chicago area for several years. But, as the media industry began to tighten its belt, Michelle’s hours were significantly reduced. So, she took a leap of faith and devoted all her time to running her side business, Mimi Productions, a television, video and production company.

But managing her own business also meant sacrificing the medical coverage she had received through the union she had belonged to while working for the network. To treat her condition, Michelle relied on several medications, including Enbrel®, a crucial medication to anyone suffering from an immune system-related disease such as AS.

She was able to cover the expenses of her insurance premium plus her medication for about year, until the financial burden just became too much.

“The costs just kept adding up. It’s dramatic,” she says. “If I don’t take my medication, I’m in so much pain it’s unbelievable. And if I don’t have my Embrel®, I can’t work.”

Luckily, several contacts that she met through the Spondylitis Association of America told Michelle about the Patient Access Network. And in a relatively short period of time, Michelle was able to qualify for assistance to help pay for her medication.

“The Patient Access Network covers my entire monthly co-pay, which is almost $400 a month. It was a godsend,” according to Michelle. “Not only is my pain under control, but I don’t have to worry about where the money is going to come from.”

Visit the Patient Access Network Foundation if you think you or a family member could qualify for coverage.


COBRA Subsidies Have Ended. What Now?

COBRA, the program that allows people who have lost health insurance coverage through their employer continue the coverage for a fee, just got a lot more expensive for a lot of American families.  On September 1st, 2011, Federal COBRA subsidies ended for the thousands of individuals who qualified for coverage between September 2008 and May 2010.  Under the subsidy plan the federal government helped to pay for 65% of your health insurance premiums, but the program ended in August of 2011.

If you are losing the COBRA subsidy or just becoming eligible for COBRA, what should you do? The first thing is not to panic.  There are options out there, and COBRA can be some of the most expensive individual health insurance. When you choose COBRA, you are deciding to keep the same plan that you had with your employer, yet now you pay the full premium (both your share and what used to be your employer’s share) plus a small administrative cost. Premiums of $400 to $500 a month for individual plans and more than $1,000 a month for family plans are pretty common for COBRA.

Depending on how you qualified for COBRA (you lost your job, your spouse lost their job, your hours were reduced, or another reason), you can generally keep COBRA for 18 months. So this means three months where you must pay 100% of the premium in order to stay covered.

For more affordable options, you may be able to find insurance through:

A spouse or partner’s employer plan: Even if your partner’s plan requires a premium payment it is likely to be cheaper than COBRA.

Your state’s Pre-existing Condition Insurance Plan (PCIP): This plan was passed with the Affordable Care Act (the 2010 health reform bill) in order to create an option for people who have been denied coverage because of a pre-existing condition. Find your state’s plan at www.healthcare.gov.

Medicare: For individuals age 65 and above or who have been eligible for Social Security Disability payments for at least two years. The State Health Insurance Assistance Program, SHIP, can help you understand your benefits: https://shiptalk.org.

Medicaid: For individuals with low income. Every state has a different set of rules and eligibility levels.

Children’s Health Insurance Program (SCHIP): Insurance coverage for your children. www.insurekidsnow.gov

An individual plan: If you do not have a pre-existing condition and do not qualify for any of the options above, buying a plan on the individual market is likely your best bet for finding affordable coverage.  You can use a site like eHealthInsurance.com to search for, compare, and apply for plans, or you can also go the old-fashioned route: when we asked people on Facebook their best money-saving tips for applying for insurance, several answered that they had gotten great plans from brokers.

No matter what insurance plan you choose, be sure to understand all the co-pays, coinsurance, and deductibles. If your COBRA plan has low cost-sharing, it may be worth keeping, even if the premiums are high.   Use your Simplee account to understand what your spending has been like; that will help you compare plans.


Getting The Most Out Of Your Health Insurance Plan

Health plans certainly come with no shortage of rules. And you’ll want to be sure to follow them in order to get the most out of your coverage.

1) Find the freebies.

If you joined your health plan on or after September 23, 2010, you can get many preventive care services free of cost. Yes, that means no co-pay or coinsurance, even if you have not met your deductible.  This includes services such as cholesterol and diabetes screenings, women’s exams, osteoporosis tests, STI (sexually transmitted infection) counseling, immunizations, smoking cessation evaluations, depression screening, many screenings for children, and more. For a complete list, visit www.healthcare.gov.

Even if you were enrolled in your health plan prior to September 23, 2010, the plan may still offer the same preventive care benefits, so it is worth investigating.  Check out the “Your Plan” tab in your Simplee dashboard to see details of what your plan offers.

In addition, many plans also offer benefits such as discounts on gym memberships, weight-loss programs, or vitamins. After all, most everything that keeps you healthy and away from the doctor will save both you and your plan money in the long run.

2) Use your network.

If you have an HMO or PPO, your plan contracts with a network of providers. You are probably already aware that seeing physicians within the network will save you money. But plans may also contract with network hospitals, labs for blood tests, medical supply companies, home health providers, or imaging centers. Checking to see if these providers are a part of your plan before going to them for services can also save you money.

And after you have received the service, make sure to check your claim over on Simplee to make sure that you were properly charged.

3) Plan around the deductible.

Many plans have an annual deductible. For example, if your deductible is $500, you must pay $500 out of pocket for your medical care before the plan starts paying for any covered services. If you reach your deductible during the year, it may save you money to take care of any other health needs you have that year, before your deductible renews. Or if you know you will be incurring a number of health expenses that will put you over your deductible, you may want to plan them to fall within the same deductible year so you do not end up needing to meet the deductible twice. If for example you have a calendar-year deductible and you are planning a series of procedures, you may want to avoid scheduling the first in December, in case they lapse into January.

Also keep in mind that some plans may have a separate deductible for in-network providers than for out-of-network providers—you might be starting from zero if you go out of network, even if you’ve already met the in-network deductible.

4) Ask about your drugs.

Every health plan has a formulary, or list of drugs that are covered. Formularies often divide drugs into tiers, or different levels of coverage: For example, a tier 1 drug may have a $35 co-pay while a tier 2 drug has a $10 co-pay. Doctors often have no way of knowing the level of coverage for a drug on your plan when they are prescribing it. Before filling a prescription, you can check the level of coverage with your plan. If it falls on a more expensive tier (or is not covered at all), ask your doctor if there is a similar or equivalent drug you can take which might have better coverage.

5) Understand utilization management.

Many plans now use a process called “utilization management,” where certain procedures must have prior-approval from the plan before they are covered. You should find out if your plan has such requirements. If so, always make sure you have gone through all the steps to get a service authorized before you receive it. Usually, it is up to your doctor’s office to contact your insurance company to start the utilization review, but it is ultimately your responsibility to make sure it gets done.

Above all, the best way to get the most out of your plan is to understand the rules. Every health plan is different. Sometimes, the rules can even be different for two people with the same plan, depending on when each of them joined. You can view all the details about your specific plan when you log in to your Simplee account. If you have any additional questions, call the plan—it’s best to know so you don’t get that surprise bill later on.