Care Coordination In the context of a physician’s office, Care Coordination (also called Case Management) is a process that links children with special health care needs and their families to services and resources in a coordinated effort to maximize the potential of the children and provide them with optimal health care. In their important role of providing a medical home for all children, primary care pediatricians often have a vital role in the process of Care Coordination, in concert with the family.   Care coordination is often complicated because there is no single entry point to multiple systems of care, and complex criteria determine the availability of funding and services among public and private payers. Many insurance companies employ nurses as case managers. These case managers are assigned to enrollees with complex medical conditions. They can be very beneficial to the patient and the patient’s family. Does insurance cover Care Coordination? Remember, there is never a single response for insurance because there are so many different types of insurance but the numbers of companies reimbursing Care Coordination are few. Check with your Insurance company.

 

Claims Processing Tips If you are insured through an HMO, you will rarely, if ever, see the actual bill for your health care services.  Once you have paid your visit fee or co-payment at the doctor’s office or hospital, the rest of the billing is taken care of between the provider and the HMO themselves. Insurance companies pay claims for indemnity-type policies differently.  Most health care providers will submit claim forms directly to your insurance company for reimbursement.  However, some providers may want to be paid by you, and then you are responsible for getting reimbursement from your insurance company.  You will have to submit your copy of the hospital or physician claim form, together with any necessary supporting documentation, for approval by the company.  Supporting documentation can include the doctor’s office notes, lab reports, or operative reports, depending upon what service was provided. Once the insurance company receives the claim form, it reviews the claim and tells the provider what it will pay for the services.  The insurance company also sends you, the insured, a form known as an “EOB” (“Explanation of Benefits”) that tells you the same thing about your claims. It is very important for you to look at your EOBs and any doctors’ bills you get.  You should make sure the services listed on an EOB match the services you received.  If a service is not covered, or is only partially covered (if, for example, you have to pay a 20% coinsurance), the EOB will help you understand what you will be billed by the doctor or hospital after the insurance company pays its share. It is important that you create a good record keeping system for your EOB’s.

 

COBRA The Consolidated Omnibus Budget Reconciliation Act of 1986 is what COBRA stands for. Under federal law, COBRA allows continuation of group health coverage for employees or their families who lose coverage as a result of either a voluntary or involuntary termination of employment, reduced hours, death or divorce.  It applies to companies that provide health plans for twenty or more people.  The period of continuation of coverage may vary between eighteen and thirty-six months depending on your situation.  If you choose to continue your coverage under COBRA, your employer can charge you an additional 2% on top of your premium as a processing charge.  At the end of the continuation of coverage period, you or your family may be offered a “conversion” plan by the insurance company.  The new policy may be different than the one available under the company plan.  I am with a group Insurance that qualifies for COBRA, But I am leaving my Job and moving to another state. Will COBRA cover me? As a COBRA recipient, you are considered part of the group, and are provided with the same coverage, and subject to the same limitations, as the other members of your employer's HMO group contract. You still must continue to use participating providers. If you move to a state that does not have physicians and hospitals that are participating providers in your HMO, the HMO will only cover you in a true emergency situation.

 

Coinsurance, Co-payment and Deductible Amount (or percentage) of the cost of medical services that you are required to pay before insurance will pay the balance. You may or may not be responsible for these costs under your health plan so you need to review your plan’s coverage information closely. Coinsurance is the percentage you pay to the provider as your share of the cost of a medical service. For example, if your physician charges $100 for a service and your health plan has a 20% coinsurance payment, you would be responsible for paying $20 of the charges and your health plan would pay $80. Co-payment is the fixed dollar amount you pay to the provider as your share of the cost of a medical service. For example, if your health plan has a $10 co-payment for an office visit, you would be responsible for paying $10 every time you visit your doctor’s office. Deductible is the amount of medical expenses that you must incur during a particular period (usually a year) before your health plan begins to pay. For instance, if your health plan has a $200 deductible per 12-month period, you would be responsible for incurring $200 worth of medical services within 12 successive months before your health plan would begin reimbursing for covered services.

 

Coordination of more than one policy  Most group health plans use a process called Coordination of Benefits (COB). COB is a method of calculating payments between the primary and secondary plans so that no more than the actual charge is paid on a claim. Without COB, claims would be overpaid and insurance rates would rise as a result. COB is designed to give group members all of the coverage they are entitled to without exceeding the actual cost of the care received. With COB, the member receives the full benefit of their health plan and the secondary coverage is not charged for care that should have been paid by another carrier.

 

Drug List or Drug Formulary   A Drug List or Drug Formulary is a list of drugs that has been pre-approved and is preferred by your insurance provider. Pharmacy expenditures constitute one of the fastest-growing healthcare costs. As a result, many health plans are adopting new policies to control use of medications.  Many believe these new policies that raise questions about appropriate access to pharmaceuticals in private-sector health plans.  Such concerns have led 29 states to enact laws requiring managed care organizations to disclose their drug formularies and/or the procedures their members can use to obtain nonformulary drugs. An important question for Medicaid recipients—particularly those now enrolled in managed care arrangements—is how good their access is to the new medications used in treating medical issues such as mental illness, which are more expensive. It is advisable to take your preferred drug list with you to your physician and if your doctor believes that there is a better medication for your specific needs that they can begin the prior authorization request to Medicaid or your privet Insurance.  The following Medicaid Preferred Drug list  can be found at SC Medicaid Preferred Drug List. pdf

 

Dual coverage Dual coverage is when an individual is covered under two or more GROUP health insurance policies. Generally, one policy will have the obligation to pay first (the “primary” policy) while the other policy (the “secondary” policy) will pay only after the primary policy has paid.

 

et al Abbreviation for “and others.”

 

Exclusions Medical services that are not covered and for which the health plan will not pay.

 

Gaps in coverage (How do you make sure there aren’t gaps in your child’s coverage?) There probably are gaps. No insurance coverage is going to pay 100% of everything your child needs. You should understand what your insurance covers and more importantly, what it doesn’t cover. Then look for community resources, school programs or government programs to help you fill the gaps.

 

HIPAA The Health Insurance Portability and Accountability  Act of 1996 (HIPAA) contains protections both for health coverage offered in connection with employment (group health plans) and for individual insurance policies sold by insurance companies (individual policies).  These provisions deal with pre-existing conditions, privacy of information and other important topics. Try this link:

http://www.cms.hhs.gov/HealthInsReformforConsume/

 

What does this mean when my employment changes? If you find a new job that offers health coverage, or if you are eligible for coverage under a family member's employment-based plan,  HIPAA includes protections for coverage under group health plans that: 1) Limit exclusions for pre-existing conditions, 2) Prohibit discrimination against employees and dependents based on their health status, and 3) Allow a special opportunity to enroll in a new plan to individuals in certain circumstances.  If you choose to apply for an individual policy for yourself or your family, HIPAA includes protections for individual policies that guarantee access to individual policies for people who qualify, and guarantee renew ability of individual policies.

 

Lifetime Maximum Benefits The maximum amount a health plan will pay in benefits to an insured individual during that individual's lifetime.

 

Medical Diagnostic Code (What is a medical diagnostic code (or diagnosis code)?  A concise numeric shorthand description of a medical condition that is used in medical documentation and billing.  Why are they important? Once it is assigned, a medical diagnosis becomes a permanent part of the patient’s medical record. These codes are important in processing a claim.  Can they be used in the ‘wrong’ way? Yes, codes can be used fraudulently. For instance, a policy may not cover cosmetic surgery.  The diagnostic code could be intentionally changed to misrepresent the condition. If the insurance company finds out that this has been done and claims paid incorrectly, the insurance company will try to recover any money paid. If this is done intentionally on claims filed to Medicare or Medicaid, it is covered by the False Claims Act and is very serious.  Can they be mistakenly coded? An incorrect diagnostic code can be mistakenly entered misrepresent the condition and in some cases not allowing the clam to be covered. When claims have been denied it is important that you check that it has been coded correctly.  If this is the case you will have to go back to the physician to have it re-coded. The insurance company cannot correct his.

 

Medical Home A physician or medical practice that has primary responsibility for monitoring and coordinating all of your healthcare needs.  When capitalized, this is a term specifically used by DHEC and Medicaid.  A medical home addresses how a primary health care professional works in partnership with the family/patient to assure that all of the medical and non-medical needs of the patient are met. A medical home is defined as primary care that is accessible, continuous, comprehensive, family centered, coordinated, compassionate, and culturally effective. A medical home includes:

· A partnership between the family and the child's/youth's primary health care professional

· Relationships based on mutual trust and respect

· Connections to supports and services to meet the non-medical and medical needs of the child/youth and their family

· Respect for a family's cultural and religious beliefs

· After hours and weekend access to medical consultation

· Families who feel supported in caring for their child

· Primary health care professionals coordinating care with a team of other care providers

Through this partnership, the primary health care professional can help the family/patient access and coordinate specialty care, educational services, in and out of home care, family support, and other public and private community services that are important to the overall health of the child/youth and family. A medical home is not a building, house, or hospital, but rather an approach to providing comprehensive primary care.

 

Medicaid and Private Insurance (Can you have Medicaid and Private Insurance at the same time?) Yes, Your private insurance will be your primary insurance and Medicaid will be your secondary or “payer of last resort”.  Your provider will submit your clam to your primary insurance company first.  After the claim has been paid any non-covered amounts may be submitted to Medicaid.  Only providers may submit Medicaid Claims.  Reminder: Be sure to ask your provider if they accept Medicaid as a secondary insurance.  If they do not it will be your responsibility to pay the difference.

 

Medically Necessary Services Healthcare services and supplies that are appropriate and necessary based on diagnosis and cost-effectiveness, and that are consistent with national medical practice guidelines as to type, frequency and duration of treatment. The fact that a physician has performed or prescribed a procedure or treatment does not necessarily mean that such procedure or treatment will be considered medically necessary by your health plan.

 

Networks (How do I find out who is in my child’s insurance network?) In-network means you receive treatment from the doctors, clinics, health centers, hospitals, medical practices, and other providers with whom your plan has an agreement to care for its members, i.e. the plan’s network of providers. You generally have fewer out-of-pocket costs when you use in-network providers. Some health plans require members to use only in-network providers in order for services to be covered. Other health plans may cover services provided to the member by out-of-network providers but at a higher cost to the member. Your insurance company should provide you with a list of participating providers.; if they don’t call and ask them for one or ask the provider if they are participating or not.

 

Payment caps Limitation on the amount a health plan will pay for a particular service, either over a certain period of time or over the life of the policy.

 

Pharmacy Benefits (How do I find out about my child’s pharmacy benefits?) Look in your insurance booklet or call your insurance company’s customer service.

 

Pre-authorization (or pre-certification or prior authorization or prior approval) Approval in advance from your health plan for you to receive services or supplies. Coverage documents provided by your insurance company should clearly specify which services require prior approval.

 

Pre-Existing Conditions A pre-existing condition is a medical condition that is excluded from coverage by an insurance company because the condition is believed to have existed or was treated prior to the policy being issued. In most group policies, the condition has to have been treated within the six months before the effective date. The exclusion generally lasts for 12 months.

 

Policy premiums Payments made to an insurance company to cover the cost of insurance. Depending on the policy agreement, the premium may be paid monthly, quarterly, semiannually, or annually. If premiums are not paid on a timely basis, the policy will be canceled.

 

Problems with Having Two Policies (Are there problems with having two policies?) There is additional administrative work – filing claims to two insurance companies, keeping up with EOBs from two companies. You also have to pay two premiums. You should make sure the amounts of benefits potentially available under the second policy are worth the premium you have to pay.

 

Referrals (How do I know when a referral is required by my child’s Physician, and when can I make a referral myself?) Arrangement by a healthcare provider for you to see another healthcare provider, usually for specialty care. Almost all admissions to the hospital must be pre-approved. Coverage documents provided by your insurance company should clearly specify when you need a referral and when you can self-refer.

 

Rehabilitative Services The precise meaning of this term will varies by insurance company and health care professionals. Look in your insurance policy for the definition applicable to you.  In the purest sense, rehabilitative services are Services provided to an individual with a disability in preparing for, securing, retaining, or regaining an employment outcome that is consistent with the strengths, resources, priorities, concerns, abilities, capabilities, interests, and informed choice of that individual. Rehabilitation services for an individual with a disability may include:

· Assessment                                                        

· Counseling and guidance

· Diagnosis and treatment of physical and mental impairments

· Interpreter and reader services

· Job-related services

· Personal assistance services                

· Physical, Occupational and Speech-Language Pathology services

· Referral   

· Rehabilitation technology                    

· Services to the family of an individual with a physical or mental impairment to assist the individual to achieve desired outcomes

· Transportation

· Transition services

· Vocational and other training services            

What rehabilitative services are covered under the Waivers? See: Medicaid Waivers chart

 

Secondary Insurance (How can secondary insurance be helpful?) One policy may cover certain services that the other doesn’t, thereby providing a wider range of coverage for the policyholder. Also, the second coverage may pay the coinsurance and deductibles not paid by the first coverage.

Strengthening Families:

Resources for Partnering for

Healthy Development of Children and Youth