This is a GUEST POST written by Sandra Mills.
People who have chronic illnesses or any long term health condition need a health plan designed for managing complex medical conditions. It sounds simple enough, but there are many companies and many plans available. Choosing the best health plan to support a person suffering from chronic illness involves exploring coverage parameters, reimbursement and billing practices, and access to care guidelines.
One way that consumers can compare plans efficiently is to make sure they understand the industry language before contacting plan administrators. Understanding that co-insurance is a percentage of a fee and co-payments are fixed-fees helps patients compare two policies side-by-side. Carrington College has developed a guide on explaining the basic vocabulary list to help coverage seekers get past the health insurance jargon (see my post: 5 Things About Health Insurance) you need to know .
Coverage and Summary of Benefits
Insurance companies have some standard offerings and some flexibility to set pricing and coverage terms. For example, according to Kaiser Health News industry standards require insurance plans to cover annual preventive care for women, but do not give the same free-of-charge services to men. There is nothing to prevent a company from offering preventive care for men, but it isn’t required.
Also, physicians can charge an additional fee for “chronic health management” during an annual exam if the patient has complex conditions, such as cardio-vascular disease, diabetes or other chronic conditions that require a higher level of involvement.
Questions to ask:
• What are the co-pays for services and supplies?
• Is there an annual limit on any services?
• What are the deductibles and out-of-pocket limits?
Mental Health Coverage
In 1999, the Surgeon General’s Office issued recommendations that reshaped the way medical providers and patients view mental health and preventive health care. The Center for Disease Control (CDC) reports that more than 1 in 4 adults has a diagnoseable mental illness during any given year. Given this information, you might think about coverage for preventive measures and treatment options for mental disorders as a necessity, rather than optional.
The CDC report listed the following information specifically for people who have chronic illnesses:
1. Chronic illness and mental health have a circular (reciprocal) relationship. Mental illnesses provoke or complicate treatment of diseases, such as asthma or diabetes, and chronic illness negatively affects mental health.
2. Social determinants, such as income and work status impact mental well-being.
3. Physicians should incorporate mental health assessments into chronic illness management.
Billing and Practice Management
People might come across references to ICD-10 readiness. In simple terms, the ICD-10 is a set of numerical codes that medical providers and insurance administrators use to identify services and supplies. The codes make sure that a patient’s health record is accurate, that doctors and labs bill properly, and that insurance administrators pay for claims according to the policy guidelines.
New ICD-10 codes take effect in October 2014. Although this might sound like only an administrative issue, improper coding could result in reduced or denied payment by insurance companies. This could elevate stress unnecessarily, which could negatively impact the patient/provider relationship and the patients overall health.
Medical Group Management Association released study findings that 98% of percent of clinicians — physicians and other medical providers — are concerned about being able to properly code illnesses and treatments. It is important for patients to proactively approach health care. Ask how prepared prospective plans are for the upcoming transition.
Health Reform GPS reported changes in health care delivery based on the Affordable Care Act. These changes include mandated coverage for chronic care management and prevention services. The best plan should also provide the following:
• Access to physicians locally.
• Emergency care and health management coverage.
• Choice for hospitals and inpatient treatment facilities.
• Prescription options: locally or via mail order.
Finding the best health care plan for patients with chronic health conditions requires more than just finding the lowest priced policy. To get the best fit, people should consider local access, practice management policies, and coverage options along with the monthly premium.
Guest Blogger, Sandra Mills, is a career, health, and healthcare industry freelance writer. She has written several articles on health and health insurance. She can be reached on Twitter and Google Plus