Solve your health care challenges

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remiums soaring? Your insurer denied your claim? Retiree benefits got slashed? Try these strategies to cure what ails you when it comes to getting and paying for medical care.

Via money.cnn.com


Challenge # 1 - Your Premiums are too high
The employee share of premiums on company health plans has more than doubled since 1999, to $3,515 a year on average for families. Now employers are devising new ways to shift costs onto you -- moving from low co-pays to co-insurance, where you pay a percentage of the bill, or slapping on new and bigger deductibles.

The solution: Take advantage of the myriad ways your employer also gives you to save money on health care. During open enrollment, sign up for a flexible spending account, which typically lets you stash up to $5,000 tax-free to cover out-of-pocket medical bills (that max drops to $2,500 in 2013). Savings: up to $2,000 a year.

Enroll in the mail-order prescription plan -- you might pay $65 for a 90-day supply of a brand-name drug, vs. $200 at the pharmacy. And switch to a preferred or generic drug, if possible, since many companies are raising your costs on non-preferred and brand-name drugs only.

More than half of large firms are also offering incentives that can modestly lower your costs if you make an effort to get healthier. You might earn $100 in cash, say, or get a $20 lower monthly premium if you enroll in weight-loss classes. Not interested, even though you're battling the bulge? Watch out. A growing number of companies are now penalizing employees for unhealthy behaviors, most commonly by imposing a higher premium.

Challenge # 2 - You need an individual policy


More than half of adults who tried to buy an individual plan over a recent three-year period found it very difficult or impossible to find an affordable policy, according to a survey by the Commonwealth Fund. Premiums on solo policies can run two to three times more than you'd likely pay in a group plan, even though they typically cover less of your bills.

The solution: Starting in 2014, subsidies to buy individual policies will be available to low- and middle- income people. A family of four who earn less than $88,200 today would qualify. New standardized policies will also make it easier to compare plans and understand what you're buying.

But for now your best move is to try to find cheaper group coverage. Contact any professional or trade association that you might be eligible to join and ask if they offer a plan for members. One caveat: Not every health plan sold through associations is a group policy; sometimes insurers are allowed to market individual plans through the organization, warns Cheryl Fish-Parcham, deputy director of health policy at Families USA.

No luck? Comparison-shop among individual plans at ehealthinsurance.com to find your best deal. Note that prices are for people in good health; you won't know exactly what you'll be charged until you apply, but if you're not happy with the quote, you're under no obligation to buy.

A word of warning: Avoid plans that take all comers and only offer discounts on care or a limited benefit, such as a flat $500 for a hospital stay. "If anyone can qualify, it's probably not true medical insurance," warns Carrie McLean, a consumer specialist with eHealthInsurance.com.

Challenge # 3 - Your confused by Medicare

A growing number of seniors in recent years have opted to enroll in a private Medicare Advantage plan rather than the traditional government program. The draw: For an average of $40 to $74 more a month over the regular Medicare premium, you usually get a host of extra benefits. But starting next year, Uncle Sam will cut fees to the insurers that administer the plans, prompting concerns that some will exit the market, hike premiums, or slash benefits.

The solution: You can reduce the risk that you'll get socked by big changes to your plan by sticking with an Advantage plan that's been around for at least five years and, if available, earns four or five stars from the government (check ratings at medicare.gov). That's because starting in 2012, top-rated plans will get a bonus from the feds that will offset some of the fee cuts. Plus, if your insurer alters the plan, you'll get advance warning, and will be able to switch out during open enrollment, before the changes go into effect.

Usually, though, if you have serious health problems, travel a lot, split time between two homes, or just want to see any doctor you choose, you're better off with traditional Medicare. That's because you generally have to stick with doctors inside the Advantage network or, if the plan allows, pay more to see an outside provider. If you go the traditional route, you'll probably want to buy Part D drug coverage and a Medigap policy to help pay your deductibles and co-insurance. Together those plans often have higher premiums than Advantage, but you'll pay less out of pocket if you fall ill.


Challenge # 4 - Your claim was denied


A sampling of states suggests that about 10% to 15% of health claims are denied by insurers. Even more worrisome, experts say denials are growing in previously rare categories such as oncology.

The solution: Don't back down. Your chances of winning a reversal are actually pretty good if you follow the process and deadlines specified in your denial notice.

Make your appeal in writing, send it by certified mail, and request a return receipt. Directly address the reasons the insurer gave for the rejection and include as much documentation as possible.

You went out of network? Explain your area had no in-network doctors for your condition. The insurer claims the care wasn't necessary? Describe your illness, prior failed treatments, and the consequences of not getting care; tuck in your medical records and a doctor's note. The procedure is too experimental? Follow the same process, and include medical journal articles showing the treatment can be effective, says Jennifer Jaff, executive director of Advocacy for Patients with Chronic Illness. Find abstracts to help at pubmed.gov or a medical library.

Denied again? Seek help -- typically you're allowed two appeals. Some state insurance departments of attorney general offices offer a patient advocate, or you can hire your own (for a flat fee of, say, $400 or a percentage of your recovered claim). Get more information atpatientadvocate.org or find an advocate at healthcareadvocates.com.

Still no luck? You often have one final shot with an independent third-party review board making the decision, either through your employer plan or your state insurance regulator. If that fails, don't forgo treatment. Instead, talk to your doctor and ask if he will work with you on a payment plan to make the treatment affordable.

Challenge # 5 - Your retiree health plan benefits were slashed

Retiree health benefits are a dying breed: Only 28% of companies now offer them to employees younger than 65, and 21% to those who are older. If you still have coverage, get ready to pay more: Employers are shifting more costs onto retirees, starting benefits at a later age, or requiring longer tenure to qualify.

The solution: If your former employer cuts your benefits entirely and you're too young for Medicare, you'll need to buy an individual policy. If you're healthy now, you'll save a lot on premiums by going with a high-deductible plan with a health savings account, which allows you to save up to $6,150 a year ($7,150 if you're 55 or older) for future health care costs. But your bills could quickly add up if you get sick.

Already 65 or older? You'll have 63 days to buy supplemental Medigap and Part D drug coverage to replace your company plan.

Rather than an outright elimination of benefits, though, you're more likely to be hit with higher premiums, deductibles, and co-pays. Even with these higher costs, you'll probably still end up paying less for care by sticking with your retiree plan. That's because company plans typically limit how much you can pay out of pocket and don't have coverage gaps like Medicare's doughnut hole for drugs.


Challenge # 6 - You've got a pre-existing medical condition


More than one-third of adults who try to buy health insurance on their own are turned down or charged more because of a pre-existing condition or have that condition excluded from coverage, the Commonwealth Fund reports. Health reform will prohibit insurers from rejecting children on this basis later this year. But the protection for adults does not begin until 2014.

The solution: If you've gone without insurance for six months or more, you'll be able to buy coverage at rates comparable to those paid by healthy people starting in July through a new national high-risk pool created by the health reform law. Otherwise, you'll have to wait more than three years for relief.

In the meantime, try to get on a group plan, which covers all members, regardless of health status, at the same price. (You may have to wait three to 12 months for the preexisting condition to be covered.)

Another option: Seek help finding an affordable individual policy from a licensed health insurance agent (find one at nahu.org), who can often steer you to an insurer that is friendlier to your condition.

Your last resort should be seeking coverage through an existing high-risk insurance pool; most states have one or a similar backstop. But your wallet will take a beating: Premiums can run up to three times as much as the average rate in the individual market. Find out the details about high-risk coverage in your state at naschip.org.


Challenge # 7 - You lost your job....and your health care 


With nearly one in 10 Americans out of work, this scenario is all too common lately. In a few years, when the individual insurance exchanges that are the centerpiece of health reform are created, you won't have to worry about losing access to health coverage when you lose your job. But for now, at least, your options are more limited.

The solution: If your spouse has a group plan you canjoin, that's clearly your best bet. Otherwise, you can stay on your former employer's group policy for up to 18 months, courtesy of the federal law known as COBRA (companies with fewer than 20 employees may be exempt). Sure, it's expensive, since you'll have to pick up the full tab, but it's still usually your next cheapest option for comprehensive coverage. (If you were laid off between Sept. 1, 2008, and May 31, 2010, you may qualify for a 65% government subsidy to help defray the cost; go to dol.gov for details.) You have 60 days to sign up and, in case you get a job in the meantime, you can wait until near the end of that period to enroll -- coverage will be retroactive.

Currently in the priciest Cadillac version of your company options? You can downgrade to a less expensive one when you sign up. If you can't swing that $1,000-plus premium, you can go with an individual plan with a big deductible. Those policies start at around $300 for a family but can cost thousands if you get sick. Avoid short-term plans, which cover catastrophic care and usually last only one to 12 months. They may cost a bit less than a typical bare-bones policy. But if you develop a condition while in this plan and you're forced to buy a regular individual policy after it expires, you're likely to pay more or face exclusions