What is a Prior Authorization?

As a patient who takes control of your healthcare, it is important to know the terms and conditions around when a prior authorization is needed. The range can be significant – some health plans only require authorization for major elective medical services, while others may require an authorization for nearly any service that is non-emergent as well as many drugs. Prior authorizations, also known as pre-certifications, are used within the healthcare industry to ensure that an insurance company has some level of control over the medical services that its members seek. And to ensure that a patient isn’t having an elective MRI every 3 months for no medical reason, or that they aren’t getting brand name prescriptions at $15,000/month when a generic at $5,000/month will do, health insurance plans build in the extra step of authorizations. Our advice, when in doubt, is to call your health insurance plan and verify that you do or don’t need an authorization. There is typically a phone number on your insurance card dedicated to authorization questions, and especially on potentially high-dollar services, using that number could save you significant money. We also recommend that any time you call for an authorization, ask the person you talk to document the discussion in their system, and be sure to document it on your own as well. Include the number you called and the name of the health insurance employee who you spoke with. If you do receive an authorization, it will either be given in the form of a number or a document. If a number, you will need to keep it for your records... read more

What is an Explanation of Benefits (EOB)?

An EOB, or a Remittance Advice, is the documentation from your insurance company showing how they processed your claim. It should show the amount billed by your provider, the amount paid to your provider per the contract, any reasons for not paying or for denying part of the claim, and the amount that you owe. The EOB is an important document to have available if you need to discuss your bill with your provider or your insurer. There is no standard format for EOBs, but they all have generally the same elements. What is a denial from an insurance? Sometimes your insurer processes your claim and determines that they are not going to pay part or all of it. This is known as an insurance denial or rejection. When your service is denied, you will usually receive an EOB with a code or description explaining why it was denied. In many cases, an insurance denial may become your responsibility to pay. Why would my insurance deny service? Services are denied for many reasons, usually accurately but sometimes inaccurately. Common reasons why your claim may be denied include duplicate bills (the insurer was billed twice for the same service), the service was not covered by your plan, or the treatment was miscoded by your provider. These are just a few of the reasons – there could be dozens, but it should be clearly communicated on the EOB. How long should it take for the claim with my insurance to be resolved? It depends on several factors, but most claims which have no major issues are resolved within 45 days. What... read more

Health Insurance Types: HMO, POS, PPO

What is the difference between an HMO, a PPO, Point-of-Service plan, Indemnity, and other choices? If you are lucky enough to have several options to choose from when selecting health insurance, you’re probably faced with a decision of which type of plan to go with. We’ll try to simplify this, because even within the healthcare industry the lines are fuzzy and blurry. Think of these plans as less of unique entities, and more of a gradient of options that have some overlap in them. In simplest terms, you as the buyer of a health insurance plan need to make a choice: What kind of flexibility do you want in your health coverage, and what price are you willing to pay for it? After you sort out the fine print and term limitations, it all comes down to that. We’ll list the plans from high-flexibility, high-price to low-flexibility, low-price. Remember, this is just a general guide. Your health plan options may be quite different, and increasingly they will not even go by the acronyms listed below – insurance companies are always trying to find more attractive names for their offerings, such as “Choice“, “Plus“, or “Value“. When comparing your health plans in an employee handbook, skip over the text and go straight to the comparison tables where you can see the plans side-by-side. That is where the differences emerge. Health Maintenance Organization (HMO). An HMO typically is the lowest-cost option that you’ll find, with the exception of a High Deductible Health Plan (HDHP) / Health Savings Account (HSA) option, which is really a different approach altogether. HMOs typically have you choose... read more

What is a Flexible Spending Account? (FSAs)

Flexible Spending Accounts (FSAs) are accounts specifically setup to allow workers to spend pre-tax dollars on health expenditures. FSAs are very common, approximately 9 of every 10 employers offered an FSA option for their employees. Unless you are self-employed or unemployed, the odds are that you can use an FSA to help decrease the cost of your healthcare spending. An FSA is commonly operated through an administrating company, which may or may not be the same administrator of other employee benefits. FSA dollars may be spent on eligible health expenses, on insurance premiums, or on eligible dependent care expenses. With most employers, sign-up for FSAs occur during the benefits open enrollment period, or during a “life change” window such as a marriage or the birth of a child. Like Health Savings Accounts (HSAs), FSAs are intended solely for health expenses and are regulated. The process for saving and spending FSA dollars are dictated by federal policy, and in many cases your employer or administrator may have additional regulations or requirements. Unlike HSAs, FSAs are offered employees regardless of which health plan they choose (an HSA is only available to employees who also choose a qualified High Deductible Health Plan). While HSAs build and grow from year-to-year like a 401k or IRA, FSAs have a “use it or lose it” provision. The dollars saved must be spent within the same benefit... read more

CDC and Humana Partner

CDC and Humana Partner to Create Next Generation of Public Health; Alliance to Leverage Private-Sector Resources to Address Chronic Diseases. The Centers for Disease Control and Prevention (CDC) and Humana Inc. (NYSE: HUM), the nation’s leading consumer-oriented health benefits company, have entered a partnership with the aim of expanding on traditional private- sector approaches to population health management. The partnership will leverage Humana’s resources and technologies, including the ability to discover, target and intervene on individual health risks and the expansion of that capability to the entire U.S. population. “As an industry we need to make a greater commitment to addressing chronic diseases and the costs they impose on our healthcare systems and individual well-being,” said Dr. Jonathan Lord, Humana’s senior vice president and chief innovation officer. “Among the initiatives we will focus on are ways to use public health data to predict and identify those at risk for diabetes and other chronic diseases.” The University of Miami–Humana Health Services Research Center will lead the research effort with an initial focus on health screening tools and chronic disease interventions using voice activated technology, mobile phone applications and social and community-based interactions. A particular focus will be on expanding current work being conducted at the Center that correlates the effects of wellness programs to reductions in weight, increased activity levels and lower medical claims costs for employer groups. The partnership will expand upon that body of work by further analyzing Humana’s rich medical and lifestyle data to refine the CDC’s Healthy Workforce USA program, a new initiative from the CDC Office of Innovation that will define best practice metrics and program components... read more

2021 Medicare Prescription Drug Plans

Medicare Part-D (drug coverage) helps pay for the prescription medications you need. Even if you don’t take prescription drugs now in 2021, you should consider getting Medicare drug coverage or other creditable prescription drug coverage because you’ll likely pay a late enrollment penalty if you join a plan later. Generally, you’ll pay this penalty for as long as you have Medicare Part-D coverage. Medicare Part-D is optional and is offered to every senior with Medicare. If you are looking for extra drug coverage in 2021 you can use this guide to help compare Medicare plans offering additional Part D coverage. Medicare enrolled seniors cant start signing up until October 15 2020. Open enrollment runs through December 7... read more

2021 Medicare Advantage plans

Medicare health plans and prescription drug plans can make changeseach year—things like cost, coverage, and which providers andpharmacies are in their networks. Plans also can change their providernetworks throughout the year. If you’re in a Medicare health orprescription drug plan, always review the 2021 materials your plan sends you(like the Annual Notice of Change and Evidence of Coverage) and makesure your plan will still meet your needs for the following year. If you’resatisfied that your current plan will meet your needs for next year andit’s still being offered, you don’t need to do... read more

2021 Medicare and You Handbook

Your Medicare options. When you first enroll in Medicare and during certain times of the year, you can choose how you get your Medicare coverage. There are 2 main ways to get Medicare. Plans must cover all of the medically necessary services that Original Medicare covers. Most plans offer extra benefits that Original Medicare doesn’t cover—like some vision, hearing, dental, routine exams, and more. Plans can now cover more of these... read more

2020 Medicare and You Handbook

Original Medicare is one of your health coverage choices as part of Medicare. You’ll have Original Medicare unless you choose a Medicare Advantage Plan or other type of Medicare health plan. You generally have to pay a portion of the cost for each service covered by Original Medicare. See the next page for the general rules about how it... read more

Understanding The Medicare Donut Hole

What is the Medicare “Doughnut Hole”? How is the Medicare Part D Doughnut Hole broken down in terms of dollars and cents? How will the Doughnut Hole effect me? If I receive a Low Income Subsidy from Medicare (i.e. extra help) how will the Doughnut Hole affect me? Will I hit the Doughnut Hole? When will I hit the Doughnut Hole? When will the average Medicare enrollee hit the coverage gap called the Doughnut Hole? Do I still have to pay my monthly Medicare Part D premiums while I am in the Doughnut Hole? What expenditures count towards the $2850 level that puts me into the Doughnut Hole? What is the reason that the government created a Doughnut Hole in the Medicare prescription plan? Will the Doughnut Hole be the same in 2015? How many people will hit the Doughnut Hole in 2015? What are out-of-pocket (OOP) expenditures? What expenditures do not count towards my out-of-pocket expenditures? What is the catastrophic coverage point? What other issues are there with the Medicare Part D program that may affect me? How can I avoid the Doughnut Hole?       What is the Medicare “Doughnut Hole”? The Medicare Doughnut Hole is the gap in the 2014 Medicare Plan D coverage between $2850 and $4550 in prescription drug spending. (Please see below for an important note on how your prescription drug spending costs are calculated.) During this gap in coverage, you’ll pay 47.5% of the plan’s cost for covered brand-name prescription drugs and 72% of the price for generic drugs. In 2014, this is a gap in coverage of $1700 that you must... read more

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