50 Ways to Afford Health Care

Wednesday, October 17, 2007

By Grace Hammond

Jackson Hole, Wyo.- Too bad you were using ropes when you had that climbing accident.

If you’d been free-climbing, your health insurance policy might have covered your claim. Some independent policies will deny any “climbing accident where ropes were used,” said local insurance agent Tom Sheue.

Many major independent insurance companies refuse to insure pilots, professional athletes, ski instructors, bartenders and…models? “They’re too high risk for anorexia or bulimia,” Sheue explained.

It’s all part of the topsy-turvy, baffling world of American health care.
“People don’t view health care as a business,” said Christine Johnson, a local claims manager. “You have to shop around. If you polled 100 people, you’d find probably five that do.”

You are a customer. You can be savvy about health care like you are when you clip coupons for groceries, play hardball at the car dealership or shop for the best deal on phone service.

Local health insurance agents, doctors, urgent care employees, social service providers, a public health employee, a Medicaid specialist, and a former claims worker for Cigna provided suggestions to save money and avoid spendy mistakes.

“Consumers have got to realize they’ve got more rights than they ever knew about,” said Dawn Sheue.

The tips below can’t fix the big-picture problems in our health care system. What they can do is empower the patient to ask questions, know their options and steer clear of pitfalls along the way.

SHOP SMART FOR HEALTH INSURANCE.
Get group health insurance through an employer - but don’t expect a free ride. “Group medical insurance is ‘guaranteed issue,’” said Linore Wallace, an agent at HUB Insurance. You can’t be denied coverage because you are sick, pregnant or high-risk (that’s you, climbers!).

It is increasingly difficult to find employer-provided plans because costs are going through the roof. According to Fred Brock’s “Health Care on Less Than You Think,” Starbucks now spends more on employee health insurance than the raw materials for coffee. In 2005, average individual out-of-pocket expenses for employee-provided health care stood at $1,366, and costs are only getting higher.

Get individual coverage if you don’t have access to a group policy. “I know families that have spent hundreds of thousands of dollars on medical costs because they started out without insurance,” said Dr. Bruce Hayse, a local general practice physician. But, he said, “don’t expect any good deals on private insurance – there aren’t any. Unless you’re working with an employer with a group policy, the choices you have are just dreadful.” Insurance agents, not surprisingly, disagreed. “We can always find a policy that works for someone,” said Dawn Sheue. With individual coverage, you tend to get what you pay for. For a single, 25-year-old female, local quotes ranged from $98 to $300 per month, depending on included benefits.

Understand “usual and customary fees (UCF).” These fees are “the biggest battle here, I’d say,” said Dawn Sheue. Wallace explained: “Insurance companies take a procedural code [like for an MRI, office visit or mammogram] and look at what all the doctors in Wyoming charge for it. Then they figure out the average.

That’s what [they] will pay.” If your doctor charges more, you are responsible for the difference. “Let’s say you visit the doctor for a cold,” Johnson said. “He charges $100 for the visit. If ‘usual and customary fees’ in Wyoming for a visit for a cold are $70, you have to pay the extra $30, plus your co-insurance, and it doesn’t count toward your deductible.” The reason this is so important locally is that “most of the doctors here charge more than the usual customary fee,” said Dr. Hayse.

Area health care charges are “running right along the cost of living,” said Johnson. Dr. Brent Blue at EmergAcare feels doctors aren’t the problem: “UCFs are the insurance companies’ way of ripping people off,” he said, and disagreed that the charges are always based on the state average. “They’ll use the region – the county, the state, even something like ‘the intermountain west,’ find the lowest average and that’s the UCF.” Either way, you should be willing to travel for your care, even out-of-state, to avoid these fees. It might be well-worth the gas money.

Understand pre-existing conditions. These are health problems that were present – whether you knew it or not – before you signed up with your current health carrier. Some companies deny claims or impose a waiting period on these conditions. Be careful about switching policies during a health crisis.

GET THE RIGHT INDEPENDENT POLICY.
Maintain continuous coverage. If you haven’t had any gaps in coverage during the last 12 months, some insurance companies will waive waiting periods on pre-existing conditions. Try never to be without some level of insurance.

Purchase a short-term policy during transitions. These independent policies are cheaper than paying for long-term insurance (or COBRA) and typically cover you for up to 12 months. They don’t usually cover pre-existing conditions and you may have to reapply every few months, which gives them the option to drop you if you develop a long-term problem. If they don’t renew your policy, that problem becomes a pre-existing condition when you apply to other plans.

Avoid “hospital plans,” advised Wallace. You might get fliers about these plans in your mailbox. “Nowadays, most stuff is done outpatient,” she said. “And [these policies] won’t cover medications or anything else.”

Consider a high-deductible policy. This offers a lower monthly premium, which can save you thousands of dollars a year. It’s the best deal if you have minimal health care needs and just want to make sure you won’t go bankrupt in the case of a major illness or accident. “Pick a deductible you can live with, where you won’t lose the house or the car,” said Johnson. An indemnity plan with Celtic, with a $5000 deductible and zero percent coinsurance, was quoted to me at $96.17 per month.

UNDERSTAND YOUR NETWORK.
Consider a PPO policy for a lower monthly premium. A PPO (preferred provider organization) offers you access to both in-network and out-of-network doctors.

In-network doctors are contracted with the insurance company to provide services for discounted rates and the providers can’t charge more than “usual and customary fees,” said Dawn Sheue. A typical PPO plan may pay 80 percent of an in-network visit but only 50 percent if it’s out-of-network. Here’s the catch: “There’s not many doctors here that will be involved with any of the PPOs,” said Dr. Hayes. Examine the network carefully before you sign up for a plan – you’re in for a nasty surprise if only one local doctor is in-network. You’ll be paying out-of-network rates and the UCF when you see any other provider.

Consider an indemnity policy in order to be network-free.  This type of policy makes no distinction between in-network and out-of-network doctors. You can go to any doctor or hospital you choose and the visits will be covered equally. The downside is that no doctors are contracted to provide in-network fees so you are still open to UCF charges.

KNOW WHAT YOU’RE IN FOR.
Never lie on your insurance application. Further, don’t omit details. “They’ll find out,” said Wallace. “It comes back to you and your policy can be rescinded” and all of your claims denied.

Calculate your yearly health insurance costs correctly. There’s a lot more to what you pay out-of-pocket than the deductible. To compare policies, add your annual premium, deductible, and coinsurance/out-of-pocket maximum. Consider likely out-of-network costs and UCF fees. 

Understand your policy. This is the number one way to avoid surprising and disastrous health care costs, said Johnson. “I know it’s dry reading, but it’s extremely important.”

DEAL WITH REJECTION.
Know what conditions can make you independently uninsurable. Individual policies will, in most cases, refuse to insure a person with diabetes, any history with cancer, a prior DUI conviction, asthma, a psychological disorder, or regular participation in “hazardous activities,” said Wallace. Your prescription history can also get you denied.

For example: “Prozac [used to be] defined by the American Medical Association as for manic-depressive disorders [only],” she said. If it was prescribed to you for an off-label use, you would still show a history of manic-depressive disorders. Companies have wide berth to deny coverage – in fact, if one company denies you, others may follow suit. Many people are surprised to find out they can’t get insurance because of something that happened a long time ago.

Visit the Department of Family Services to apply for Medicaid or prescription drug assistance. These programs are “income eligible,” said Jackie Lance at DFS. “Everyone has the right to apply but not everyone is entitled to the programs.” The DFS office will be closed Oct. 29 – Nov. 6 to move to their new office at 115 W. Snow King Avenue.

If you’re denied independent coverage and Medicaid you can apply for WHIP, the “Wyoming Health Insurance Pool.” WHIP is a plan of last resort. You must be a state resident, recently denied health care coverage, under 65 and without access to Medicaid or Medicare. “It’s a group plan – they have to take you,” said Dawn Sheue. The monthly premiums are “inflated,” she said, but it’s a solid alternative to going bankrupt, especially if you’re already sick. “The Wyoming pool is well-worth it for people spending a lot of money on medical costs,” said Dr. Hayse. “[It’s] not as well for the average person.” Call 634-1393 for program information. 

Apply for Wyoming Kid Care CHIP. Call the Department of Family Services at 362-5630 or dial 1-877-543-7699 to find out if your child is eligible.

KNOW THE LIMITATIONS.
Steer clear of policies that limit “airflight ambulance” payments. This is a rural area and “if something that happens to you is serious, you’ll be life-flighted [somewhere else],” said Tom Sheue. One flight to Idaho Falls or Salt Lake City can cost you nearly $10,000, he said, and some policies max out at $3000. Check your policy carefully for this kind of limitation and consider supplementing it.

Watch for “therapy” caps. Physical therapy and chiropractic benefits are often capped to a dollar maximum or a maximum number of visits. If sports accidents are your biggest concern, make sure it’s a cap you can live with.

Climbers and other athletes have special considerations. “I can’t get medical insurance for climbers,” said Wallace. “Unless they’re on a group plan, they’re going to have a hard time.” Other independent applications will ask what kind of sports you are involved in. If you write “climbing,” Tom Sheue said, they might include a clause that climbing accidents aren’t covered.  Dawn Sheue suggested: “Do your homework and get with a broker that can find the niche market for you.”

KNOW BEFORE YOU GO.
Call your insurance company about “usual and customary fees” before you make an appointment. If you know the procedure or type of visit you need, call and ask your insurer its UCF.

Get a quote from the provider. Call around for a doctor or hospital that charges UCF or less. “[Health care] is the only consumer item we don’t ask what it’s going to cost,” said Wallace. Ask the doctor if they’ll agree to charge the UCF figure, and if not, move on. 

Know how you’ll pay. Many Jackson doctors will not bill insurance – they give you a “superbill,” said Dr. Blue, which is a receipt that you can submit to your insurance company in hopes of reimbursement. Ask if they expect to be paid upfront. Don’t make an appointment you don’t have the cash to cover.

Avoid out-of-network fees by asking your PPO provider for a deal, advised Johnson. If there is no dermatologist in your network within 100 miles, call and ask the insurance company if they’d be willing to consider a visit to your local dermatologist in-network. “Nine times out of ten I’d say yes [as a claims agent at Cigna],” she said.  

BE SAVVY AT THE DOCTOR’S OFFICE OR HOSPITAL.
Tell the receptionist the right thing. If your office visit is preventative or wellness – you’re not sick – tell the receptionist to “code the visit as preventative or wellness,” said Dawn Sheue.

Make sure to tell your provider right away if you were injured on the job so you are eligible for workers’ compensation. “People  don’t report it and wind up with complications,” said Dr. Hayse.

Get your hospitalization authorized on time. Johnson said that insurance companies expect to hear you’ve been hospitalized “within a reasonable timeframe – generally 48 hours.” The hospital usually makes the call.

Ask hospital staff how many days the insurance company authorized. If they authorized two days and you stay three, you’ll have to pay for the third day.

Ask your doctor for clear explanations of tests. You don’t want payment to be denied because the insurance company deems it “not medically necessary,” so if tests seem excessive, say so. “I think it’s a smart move because it really helps a doctor to know how aggressive a patient wants to be,” Dr. Hayes said. “You do need to ask, ok, is this something I can really do? What’s the risk of not doing the test?”

Bring your drug formulary with you to the doctor’s office. If you’re prescribed a drug that isn’t on your formulary – the list of drug coverages - ask your doctor if there is a comparable drug on the list.

Write things down. Buy a “health care notebook” and jot down the details every time you go to the doctor or talk to your health insurance. It will save you time, money and frustration when dealing with claims.

Consider Urgent Care instead of the E.R. “The only charge we have here is a physician’s charge, no facility fee, and at the start we’re about 25 percent what the E.R. is going to cost you,” said Dr. Blue at Emerg+A+Care, which is both a family practice and urgent care facility. You must pay at the time of service – they don’t bill insurance – which keeps costs down, he said. “We would have to dramatically increase our rates if we dealt with insurance companies.”

GET HELP.
Make a free smoking cessation appointment with Dr. Blue. “Quitting smoking is the number one thing you can do for preventative care,” he said. Call 733-8002.

Use the library to find medical information in print or through free access to their medical databases. Call 733-2164.

Enroll in Best Beginnings for WY Babies for prenatal, well baby and parenting health services. Call 733-6401.

Visit Western Wyoming Family Planning for annual exams, STD testing and discounted birth control, charged on a sliding scale. Call 732-1694.

Visit the free walk-in clinic. You must be a resident of, or work in, Teton County, be uninsured and meet income requirements. It’s open at 5:30 p.m. on Tuesdays. Call 739-7493.

Take care of your mental health. According to Money magazine, the average cost of visiting a psychologist is $120. At the Community Counseling Center, the sliding scale begins at $5. Call 733-6289.

Visit the Community Resource Center for health care assistance, emergency referrals and dental and vision information. Call 739-4500.

Get the Guardasil vaccine that prevents cervical cancer. It is free at Public Health or EmergAcare if you are a woman between ages 12 and 18. If you are over 18, pay for the vaccine – you could save money, and maybe your life, down the line. Call 733-8002 or 733-6401.

Visit public health for free condoms with information in both English and Spanish, free HIV testing and counseling, $10 pregnancy testing, $10 suggested-donation vaccines for adults and children, inexpensive flu shots and a chance to browse their comprehensive health library. Call 733-6401.

Get medical translation services through El Puente. You should always be able to understand you doctor, and your doctor should understand you. Bridge the language barrier by calling 739-4544.

BE SMART ABOUT BILLING AND TAXES.
Always compare your bill to your Explanation of Benefits (EOB). If you have insurance and it was billed directly by a provider, you should get two items in the mail for each claim: a bill from the provider and an EOB from your insurance company that explains what they paid for. Compare the two. If there are any discrepancies, call both parties.

Request a better break-down of costs. Some bills or EOBs will list generic categories like “emergency room physician.” Call and ask for a more detailed break-down. Fight the charge if you don’t agree with it. “The insurance companies are scumbags,” said Dr. Blue. “Never take no for an answer – fight everything that’s on your bill.”

Ask for a discount. Some providers will discount your bill if you pay a certain percentage up front or in cash. St. John’s Hospital states on their website that “After insurance has paid, a 10 [percent] discount will be offered to you within the first 21 days of the billing date, if you pay your balance in full.”

Get on a payment plan for medical debts. The provider will usually work with you to create a plan you can live with. “You can chip away at it a little bit at a time,” said Lance. Call St. John’s accounting department at 739-7615 to discuss a payment plan for current hospital debts.

Be tax-smart by enrolling in a Flex Savings Account or Health Savings account at a local bank, which will tax-shelter money for medical expenses. Write off medical bills that exceed 7.5 percent of your adjusted gross income.

AFFORD YOUR MEDICATIONS.
Ask your doctor for samples.  Many doctors will provide these to you.

Shop around at pharmacies. Not all pharmacy prices are created - prices aren't regulated.

Enroll in a mail-order plan through your insurance. If you have maintenance medications, “often you can get two-for-one,” said Johnson.

Print out coupons for some prescription brands from their official website.
Enroll in a prescription-assistance program. You can get some medications for free or deeply discounted if you visit the Partnership for Prescription Assistance at www.pparx.org or call 1-888-4PPA-NOW.  

Please join the fray by sending your tips, tricks or feedback to editor@planetjh.com or commenting on our website. If you’ve got a better idea about health care costs, speak up and share the wealth with your community. Comments posted online appear immediately. 

Photo by Grace Hammond
Brent Blue, MD, shows what Emerg+A+Care has to offer.

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