Health Care & Insurance
One of the largest issues facing everyone is healthcare and insurance costs. Every year there is a substantial increase in the cost to employees and employers. Some employers are willing to absorb those costs and others pass them all to their workers. Some companies with older employees find that their rates are substantially higher than many other companies with younger employees. Now along with the cost of the premiums hitting the work force, they must face high deductibles and less benefits. With the costs rising as much as they are, it's taking a larger chuck of those employees paychecks to have the privilege of keeping health insurance.

What is the cost and what is the benefit of insurance to society? What is the cost of not having insurance for an individual? Most economists and politians would talk about the dollar cost, but what is the cost to society when many of those in it sacrifice their well-being because they can't afford to take care of themselves or their family. A healthier society and workforce would be more productive and the overall cost would end up being lower in the long-run. An ounce of prevention is worth a pound of cure, but where should the money to pay for it come from?

Most people with multiple sclerosis (MS) have health insurance provided by an employer or union. This section includes important information about how to get the most out of your coverage and how to keep covered even when changing or leaving jobs, getting divorced, when your working spouse goes on Medicare, or other changes occur.

Health Insurance

A health insurance policy is a contract between an insurance company and an individual. These policies are usually renewed annually and rate changes usually come at that time. The type and amount of health care costs that will be covered by the health plan are specified in advance, in the member contract or Evidence of Coverage booklet. The individual policy-holder is require to pay for:

Premium
The amount the policy-holder pays to the health plan each month to purchase health coverage.
Deductible
The amount that the policy-holder must pay out-of-pocket before the health plan pays its share. The policy-holder might have to pay a $1000 deductible per year, before any of their health care is covered by the health plan. Typically the higher the deductible, the lower the monthly payments are as with most insurance policies.
Copayment
This is the amount that the policy-holder must pay out of pocket before the health plan pays for a particular visit or service. It must be paid each time a particular service is obtained such as an office visit.
Coinsurance
A copayment or copay has the policy-holder paying a percentage of the total cost. For example, the member might have to pay 20% of the cost of a surgery, while the health plan pays the other 80%.
Exclusions
This would be for services that are not covered, therefore the policy-holder is generally expected to pay the full cost of non-covered services out of their own pocket.
Coverage limits
This would be the amount that the policy-holder would be expected to pay for any charges in excess of the health plan's maximum payment for a specific service. There are typically annual or lifetime coverage maximums included, so when that limit is reached, the policy-holder must pay all remaining costs.
Out-of-pocket maximums
This coverage limit benefit the policy-holder in that the payment obligation ends when they reach the out-of-pocket maximum, and the health plan pays all further covered costs.
In-Network Provider
These are providers that have agreed to specific rates or pricing limits that are less than the "usual and customary" charges with the insurance company. The insurer will offer discounted coinsurance or copayments, or additional benefits, to a plan member to see an in-network provider so both sides pay less.
Out-of-Network Provider
These are providers that don't have rate or pricing agreements with the insurance company, so the cost is more for the insurance company and the policy holder.

Prescription Drug Plans

Prescription drug plans are usually part of the health insurance package offered through most employer benefit plans. These plans will typically have the patient pay a copayment and the prescription drug insurance part or all of the balance for drugs covered in the formulary of the plan. Most have the costs of prescriptions set to different "tiers" or costs based on generic, standard, and other class of drugs. The generic usually has a lower cost for everyone, the standard are usually name brand with moderate costs, and the other class are typically very expensive and more specialized.

Without a drug plan, almost all the medications specifically used for treating MS are out of reach to those in need. If you were to pay for those medications without insurance, the cost of the disease modifying drugs would be around $2000 to $6000 every month unless you were to negotiate the cost as insurance companies do. An insurance company has greater bargaining power than a single person since they essentially buy in bulk.

There are financial aid programs that are out there that can assist those unable to afford certain medications. These programs are offered by many different sources and some by the drug companies themselves. It's a difficult decision when it comes down to food on the table or treatment and this is a place that nobody should be in.

Insurance Costs

Most would argue that the reason for rising health care costs is due to the increased consumer demand for insurance, for new treatments, and the greater use of diagnostic testing. Populations are aging and larger groups of senior citizens are requiring more intensive medical care than the younger and healthier population. Advances in medicine and technology have also had a part in the increasing cost of medical treatment. Cost have also been affected by lifestyle-related factors such as: higher rates of obesity caused by insufficient exercise and unhealthy food choices; excessive alcohol use, smoking, and illegal drug use.

Price or cost of having insurance is reaching a point that people have to choose what is more important. Some will break their medication in half and take a partial dose instead of the full dose, essentially putting their health at risk due to cost. Many people will skip a treatment because it costs as much or more than they earn that month.

This is something that must be addressed now to avoid what could end up being "health care for the wealthy" and nothing for the rest. This ends up being a political issue but doesn't have to be, it should be the right thing to do. There is a moral obligation that must be faced by the government, corporations, and essentially by individuals on how to treat another human being.

Issues With Payment

The more you use your health insurance, the more likely you will notice that they choose not to cover or pay for certain things. It's important to always make sure you verify that your coverage will pay for a procedure or treatment. If it should be covered and it's not being paid by your insurance company, then it's important to take a very active roll and ask why. Ask why that item was not paid, when it will be paid, and keep track of all your conversations with the insurance company. If later you are told again it should have been or is going to be paid, and it hasn't, you have the important information from your prior conversation to add when you have to make that next call. Most larger insurance companies, to give them some credit, are very large bureaucracy's and it's easy for claims to be entered incorrectly, so it can be a true and honest mistakes.

There are many times where a simple phone call to the insurance company will have them look at a bill and determine that it should have been paid and then it's taken care of. There are also times when they won't be willing to pay for something that is covered, this is when you need to take note and hold your ground. You don't have to yell or argue with them, just give them the facts and if you are correct, you should win. Remember to stay persistent and don't give up.

Since there isn't any law placing all insurance companies under a single federal umbrella, it's up to individual states to regulate insurance companies and how they operate in that specific state. Every state has an insurance commissioner of some type that is responsible for the oversight of insurance companies there. If you find that you can't get anywhere with the insurance company, then contact your state insurance commissioner.

Pre-existing Conditions

One big way that insurance companies can get out of paying is to claim that illness is a pre-existing condition. This can come about if there is a gap in coverage from one plan to another. So if someone were to change jobs and they were already sick, and then there was a period of time without insurance coverage, even for just one day, the new insurance company will say that it's a pre-existing condition.

The way to avoid this from happening is by making sure that you are covered by insurance until your new insurance has begun. As long as there is some type of insurance coverage either from the previous job, a COBRA policy, private coverage, or a government plan, then the insurance company can't say that there was a gap. The major issue with this is that if you aren't working and without income, you are suppose to pay the full price of the insurance premium which can be as high as a mortgage payment.

One of the biggest problems with the way insurance companies use this "condition" is when someone looses a job and can't afford to keep health insurance coverage during that period. This comes back to some difficult choices that one must make when money or lack there of is involved.

Appealing a Denial

If you believe the service, device, treatment, or medication in question should have been covered by your plan, then you should appeal. Many people don't pursue their right to an appeal because they don't believe they can win. But if you are dissatisfied with the outcome of a claim for any reason, you have nothing to lose by taking advantage of your right to request a re-consideration of the original claim. Start by re-examining your plan to make sure what you presumed would be covered actually is. It's possible to discover that a medical service or treatment is actually not covered by your policy. If something is specifically excluded from the policy, chances of winning coverage for it on appeal are slim to none. But if the policy does not mention the specific treatment in question or the coverage is unclear or framed in terms of 'medical necessity', it's to your advantage to try the appeals process.

Carefully review the explanation of benefits (EOB) form that is sent you every year. Make sure you understand the reason you have been denied coverage, partial or total. These explanations often appear as codes with explanatory notes at the bottom or on the back of the EOB. Is there a simple explanation, such as, the claim is a duplicate? Is there a mistake in the billing code, patient identification number, date of service or other?

If all this information seems in order, your next step is to understand your plan's appeal procedures. Follow these procedures carefully, especially the deadlines, as well as these basic guidelines:
● Write a very clear and simple letter providing the facts and a concise explanation of why you believe your claim should be paid. Keep your letter to one page, but be sure to include your insurance ID number, the specific claim number (if applicable), the name and contact information of your health-care provider, and date of service (if applicable).
● Keep detailed records of all interactions with your insurer, including names of company representatives you speak with on the phone and relevant dates. Keep copies of claims and bills, appeal letters and any attachments, and any other relevant communications.
● Follow up. If your appeal is denied, go to the next level of appeal. Don't assume this happens automatically—make sure you communicate your desire for a second-level appeal. This will also be an "internal appeal", but it will involve a re-consideration of your original claim among a higher level of professionals within your insurance plan. If your second internal appeal is denied, you may be eligible for an "external review" of your claim by a panel of health professionals with no affiliation to your health plan. Contact your state insurance commissioner about additional rights of appeal you may have in your state.

Be sure to discuss your insurer's denial, or other coverage issue you are appealing with your physician or other relevant health care provider and solicit their active support. If the dispute is over the necessity or value of a medical treatment, your physician's support in the form of a letter including studies supporting the benefit of the treatment in question could be invaluable. Provide copies of your appeal letter to your physician or other provider for their records.

Facts about U.S. Health Care:
In the United States, the U.S. Census Bureau figures for health insurance coverage from the years 2005 to 2006 as follows:
● The total number of people without health insurance rose from 15.3 to 15.8% which comes out to 44.8 to 47 million people.
● The number of people covered by employer based healthcare coverage decreased from 60.2 to 59.7%.
● The number of people covered by government based health programs decreased from 27.3 to 27.0%.
● The number of children without health insurance under the age of 18 increased from 10.9 to 11.7% or 8 to 8.7 million.

The U.S. spends more on health care per person than any other nation in the world. Current estimates put U.S. health care spending at approximately 15.2% of the gross domestic product (GDP), second only to the tiny Marshall Islands among all United Nations member nations. Some other facts about U.S. health care are:
● In 2007 the U.S. spent $2.26 trillion on health care, or $7,439 per person.
● The U.S. is the only wealthy and industrialized nation that does not have universal health care.
● Around 84.7% of citizens have some form of health insurance either from their employer, individually plans, or by government programs.
● U.S. government programs accounted for over 45% of health care expenditures, making it the largest insurer in the nation.
● Certain publicly-funded health care programs help to provide for the elderly, disabled, children, veterans, and the poor, and federal law mandates public access to emergency services regardless of ability to pay.
● The World Health Organization (WHO) in 2000 ranked the U.S. health care system as the highest in cost, first in responsiveness, 37th in overall performance and 72nd by overall level of health (among 191 member nations included in the study).
● Americans without health insurance coverage during 2007 were about 15.3% of the population, or 45.7 million people. Health insurance costs are rising faster than wages or inflation, and "medical causes" were cited by about half of bankruptcy filers in the U.S. in 2001.Americans without health insurance coverage during 2007 were about 15.3% of the population, or 45.7 million people. Health insurance costs are rising faster than wages or inflation, and "medical causes" were cited by about half of bankruptcy filers in the U.S. in 2001.

The Congressional Budget Office (CBO) reports that "about half of all growth in health care spending in the past several decades was associated with changes in medical care made possible by advances in technology." Other factors included higher income levels, changes in insurance coverage, and rising prices. Hospitals and physician spending take the largest share of the health care dollar while prescription drugs take about 10%.

2010 U.S. Health Care Reform:
On March 2010, the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act were both signed into law. Estimates are that by 2019, 32 million Americans will have health insurance. Since the bills were signed into law, there is still confusion over what it will do and the effect on everyone. The five major provisions that pertain to those living with neurological disorders are as follows:
● Insurance Rejection Due to Pre-existing Conditions - Effective September 2010, children with a pre-existing condition can do longer be denied coverage on their parents health insurance plans. Insurance companies will no longer be able to insure a child but refuse to pay for treatments for that child's pre-existing condition. Adults will begin receiving this coverage in 2014, so for now for any adult who has been uninsured for six months and has a pre-existing condition can enter a program known as the "high-risk pool".
● Dropped Insurance Coverage - Effective September 2010, it's illegal for insurance companies to drop people form their coverage when they become ill. This applies to all new and existing insurance plans.
● Lifetime and Restrictive Annual Limits - Effective September 2010, insurance companies can no longer place lifetime limits on coverage costs. The use of annual limits will also be greatly restricted in all new plans and grandfathered group health plans. In 2014, any use of annual limits will become illegal.
● Increased Transparency Required of Insurance Companies - By 2014, more information regarding health care providers and centers as well as the cost and quality of the care is to become available to the public. The first step began in July of 2010 when patients were given access to a Web site designed to help consumers decide which insurance plan is best for them at HealthCare.gov.
● Closing the "Donut Hole" - The current Medicare prescription drug benefits formula will change so that the "donut hole" will be phased out.