Paying the Bills
How Do I Pay The Bills?
Dealing with insurance and the cost of medical treatment can be overwhelming. The information below can help get you started.
Private and group health insurance will usually pay at least part of the cost of treatment of craniofacial conditions. When dental/orthodontia is part of treatment, insurance should cover this as well.
The following are important considerations when dealing with health insurance companies.
Does you have to have a specific diagnosis?
Does your health insurance plan address your needs?
Are there limitations on services?
Are there waiting periods for pre-existing conditions?
If you are involved with a managed care (HMO or PPO) organization, will they cover your doctors if they are not in the group?
Always request a copy of your health insurance policy, not the benefits summary brochure. The brochure is not specific enough.
Remember, the insurance company works for you.
You pay them to provide a service. When dealing with the insurance company, be sure to:
Get an 800 number; if they don't have one, ask them to call you back.
Every time you call, write down the date, the name, position and telephone number of the person you spoke with, as well as what you discussed.
Ask to be assigned a case manager from the insurance company. This person will act as your advocate through the insurance maze, as well as become more familiar with your case, in an effort to speak on his or her behalf to the company decision-makers.
If your claim is denied, be sure to appeal. The insurance companies are counting on you to accept, even though you should be covered. Below are three example letters, however for more in depth information on how to talk to the insurance company and more, go to Cleft Advocate's page on Insurance.
to write when your insurance company denies your claim.
to write when you disagree with the amount the insurance company pays on your claim.
to write to your state insurance commissioner to lodge a complaint against your insurance company.
Cleft Advocate focuses on a number of financial issues of cleft repair and treatment. Example letters are posted to assist parents, as well as to assist with state Medicaid issues. Most of the information on this website is very applicable to other craniofacial disorders and can provide excellent assistance to making your way through the insurance maze.
Patient Advocate Foundation
Patient Advocate Foundation is a national, non-profit organization that seeks to safeguard patients through effective mediation assuring access to care, maintenance of employment, and preservation of their financial stability. Patient Advocate Foundation serves as an active liaison between patients and their insurer, employer and/or creditors to resolve insurance, job retention, and/or debt crisis matters relative to their diagnosis through case managers and attorneys.
National Association of Insurance Commissioners
Provides information on the Insurance Commissioner in your state. The state insurance commissioner is the governing body that regulates the insurance companies doing business in your state. This office can assist you in determining if your insurance company is following all the rules and regulations as set forth in your policy.
Phone: (202) 471-3990
National Health Law Program
Provides extensive information on health care law affecting families whose children have special healthcare needs.
Phone: (202) 289-7661
Be proactive. Become an advocate.
Speak out; it is the only way in which health care reform will occur.
There are a variety of federal and/or state funded programs that may be able to help your child receive the care he/she needs. A few are:
State Children's Health Insurance Program
Maternal Health & Child Health Block Grants
Find Programs in Your State
Millions of children and teens qualify for free or low-cost health and dental coverage through Medicaid & the Children's Health Insurance Program (CHIP). Learn about coverage options for your family.
When dealing with public programs, be sure to:
Get a written list of benefits, restrictions, and eligibility criteria
Find someone within the program to help you through the process. Make him or her aware of your child's needs
Get involved on the advisory board for the program; you will be able to more directly affect the program
Get your legislator involved
What if you don’t qualify?
If you apply and discover you do not qualify for Medicaid, you do have the right to appeal within your state. You may appeal if you believe there were erroneous actions taken by the state agency or if the state did not act with reasonable promptness. More information on how to appeal in your state should be provided in the Letter of Eligibility notice you receive.
You also have other health insurance options. Depending on your income level, you may qualify for substantial government subsidies towards health insurance premiums via the Health Insurance Marketplace. These subsidies could result in your premium being more affordable or even free.
The Affordable Care Act (ACA) of 2010 expanded Medicaid to include individuals ages 19 through 64 at or below 133% FPL. However, you may find yourself to be one of the two million low-income adults who are not able to get healthcare coverage because your state did not choose to expand their Medicaid coverage. In these cases, you fall into what’s called the “coverage gap.” This means your income is too high to qualify for Medicaid, but it is also too low to be eligible for the premium tax credits through the Marketplace.
Unfortunately, those in the Medicaid coverage gap are limited in their options for affordable health care, and most will go uninsured. If you fall in this coverage gap, here are some alternate ways you can receive discounted medical care:
Most states and communities have income-based clinics that charge on a sliding scale, which can make doctor visits affordable. Your local health department may offer such services.
There are many prescription savings programs and cards, such as GoodRx and SingleCare, which can help offset the cost of prescription medicines. (Always try to get the generic brand, if possible, to help save.)
Needy Meds is a nonprofit organization that lists programs that help people who cannot afford medications and healthcare costs.
In the case of hospitalization or surgery, most hospitals have a charitable financial assistance program that can cover half or even all of your outstanding medical bills.
If you have the chance to open a Flexible Spending Account (FSA) through your employer, it is well worth it to set aside even $100 per pay period to go towards this account for your future medical needs.
It may be more affordable (albeit temporary) to purchase a short-term catastrophic plan through private insurance companies like Aflac, Progressive or USAA.
PRIVATE AND NON-PROFIT AGENCIES
There are numerous private and non-profit agencies which may be able to help out. Many organizations deal only with a specific disability or illness. Some organizations in your community could be: Shriner's Hospitals, Lions Clubs, Police Benevolent Associations, Civitan Clubs, Kiwanis Clubs, Sertoma Clubs, Churches, Rotary Clubs, and Junior League Organizations. If they cannot help you, always ask if they can refer you to another organization who might be able to help.
FACES: The National Craniofacial Association
We provide financial support for non-medical expenses to patients traveling to a craniofacial/medical center for treatment. Eligibility is based on financial and medical need. Resources include newsletters, information about craniofacial conditions, and networking opportunities.
Hill Burton Act
This legislative act provides funds for indigent care at hospitals where federal monies were used for construction. The hospital admissions office has information on the availability of these funds and the guidelines for eligibility.
Needy Meds is a nonprofit organization that lists programs that help people who cannot afford medications and healthcare costs. NeedyMeds has information about government programs, low-cost or free medical and dental clinics, and prescription assistance. NeedyMeds also has disease-specific financial aid programs.
The Pharmaceutical Research and Manufacturers of America (PhRMA)
PhRMA created a tool that allows patients to search for financial assistance resources offered through various biopharmaceutical industry programs to help cover the cost of medications.
Shriners Hospitals for Children-Cincinnati
All care at Shriners Hospitals for Children-Cincinnati is provided in a family-centered environment, regardless of a family’s ability to pay. Families do not have be associated with a Shriner or Shrine organization to obtain care, nor is there an application process.
The UnitedHealthcare Children’s Foundation (UHCCF)
UHCCF is a 501(c)(3) charitable organization that provides medical grants to help children gain access to health-related services not covered, or not fully covered, by their parents’ commercial health insurance plan.
There are several other things you can do to help pay for and/or reduce medical bills:
Find out if your local hospital or health care center has a private endowment fund
Itemize out-of-pocket medical expenses on your tax return
Ask your employer to set up a health care reimbursement account
Negotiate reduced payment with the hospital or doctors
Identify disability related organizations in your community
When applying for assistance, be sure to emphasize that your child's health needs affect the entire family