A Greater Understanding

Patient AdvocateFoundation• MISSION STATEMENT

Help! I'm Underinsured has beenwritten in response to the many concernsthat have been identified by PAF patients.Many Americans, even the fully insured,are still unable to pay the out of pocketexpenses, i.e. co-payments, deductibles,co-insurance, etc. that insured patientsface. Often these patients are underinsured.Financial challenges as a result of a chronic,life threatening or debilitating illness can bequite overwhelming. It is critical that youread and understand your insurance planlanguage. This is what will dictate how yourinsurance company pays for the servicesyou receive while undergoing treatment foryour medical condition. While someindigent or charity programs require noinsurance coverage to participate, there maybe other resources that an underinsuredpatient can access. This publicationstrives to provide information that willassist those struggling financially. It isour sincerest hope that Help! I'mUnderinsured will provide you withthe necessary tools to both educate andassist you in your time of need.

Patient Advocate Foundation is a nationalnon-profit organization that serves as an

active liaison between the patient and their

insurer, employer and/or creditors to resolveinsurance, job retention and/or debt crisismatters relative to their diagnosis through

case managers, doctors and attorneys.Patient Advocate Foundation seeks to

safeguard patients through effective

mediation assuring access to care,maintenance of employment andpreservation of their financial stability.

Editors Note:This is the tenth in the series "A GreaterUnderstanding" brochures developed bythe Patient Advocate Foundation. Theinformation contained herein is in responseto frequently asked questions (FAQ's) bypatients. This brochure is intended toprovide a general yet informative responseto these inquires. Any incident, inquiry orissue may vary according to these specificfacts and circumstances relating to theindividual.

• Unpaid Medical BillsThere are multiple strategies that may

be employed to help with unpaid medicalbills. You may want to discuss options withyour treatment facilities on ways to reduceor eliminate your out of pocket expenses:• Apply for financial assistance throughthe billing office at your provider's office ormedical facility.• You may first need to apply and bedenied for Medicaid to qualify forfinancial assistance from the hospital.• Co-pay relief programs may be able tocover some of your pharmaceuticalco-payments. Check with each program tosee what is covered. You can alsocontact Patient Advocate Foundation'sCo-Pay Relief Program at 1-866-512-3861to see if you qualify for assistance withyour co-payments.• Negotiate discounts with the hospitalor medical provider. Some providers willoffer a discount for prompt payment ofyour balance.• Drug replacement programs may beavailable to assist you by providing med-ications to your physician's office specifi-cally for your use. Discuss these programswith your physician.• Contact a disease specific organizationto see if there are any financial grants avail-able to assist you. These programs varywidely and may pay for transportation orother related expenses.

• Clinical TrialsAnother option you may want to con-

sider for treatment is a clinical trial. Clinicaltrials are research studies designed to testnew methods of prevention, screening,diagnosis or treatment of a disease. A clinicaltrial may provide you with an opportunity to

access new therapies while having some orall of the related costs covered by the trial.

Check with your physician to see if youmay qualify for a clinical trial. You will alsowant to check with your insurance companyto verify that your policy covers participa-tion in a clinical trial. Some trials absorbmost or all of the expenses associatedwith treatment, and can be a cost effectiveway to access quality care. For a listing oftrials you may want to contact:

National Institute of Health (NIH): focuseson all trials regardless of disease.

Call 1-800-411-1222 orvisit http://clinicaltrials.gov.

National Cancer Institute (NCI)focuses on cancer related trials.

Call 1-888-624-1937 orvisit http://www.cancer.gov.

• Insurance Policy IssuesYou need to make sure you have a

complete copy of your insurance plan.Read your policy manual and be aware ofany specific policy requirements. If yourpolicy has a preferred provider network orif there is a preauthorization requirementyou need to be aware of those beforebeginning treatment. Even a fully insuredperson may be faced with policy limits fora calendar year. Understanding your policybenefits is your best defense. A majority ofinsurance plans have a maximum out ofpocket expense per calendar year. Thisamount does not include your co-pays,deductibles and premiums. Once you havemet your maximum out of pocket expenseyour insurance company often covers all ofthe remaining charges per their contract.However, Usual and Customary chargeswill apply if you receive care outside your

provider network. This often leads patientsto have large out of pocket expenses theymay not have been anticipated. For moreinformation refer to our publication Usual,Customary and Reasonable Charges (UCR)Defined.

Another issue you may be facing is apre-existing condition rider or a waitingperiod. This pre-existing condition waitingperiod will place limits on the benefitamount or disease for which insurancecoverage is provided. The length of timefor this waiting period will be listed in thepolicy and is usually 12-18 months. Toavoid any pre-existing issues and to ensureprotection under the Health InsurancePortability and Accountability Act (HIPAA)there cannot be a lapse in insurance cover-age of more than 63 days. Once a memberis no longer covered under a plan they willbe issued a certificate of creditable cover-age to demonstrate previous insurancecoverage to your new insurer. This coverageonly applies to group insurance plans. Tolearn more about your protections underHIPAA visit http://www.dol.gov._There may be programs available toassist you with funding for out of pocketexpenses. Your physician's office may beable to advise you what resources areavailable. You may be able to access eithercommunity programs or financial assistanceprograms at your treatment facility.

• MedicaidMedicaid is a federally-funded, state-run

program that provides medical assistancefor individuals and families with limitedincome and resources that meet certaincovered guidelines. There are variousMedicaid programs available even forthose with insurance. Since Medicaideligibility requirements vary from state to

state, a person who is eligible for Medicaidin one state may not be eligible in anotherstate and the covered services may differalso. You need to check with your localdepartment of Social Services to see if youqualify for any of their programs. Also,check with your local Medicaid office tofind out if your state offers a HIPP (HealthInsurance Premium Payment) program. TheHIPP Program can pay your health insurancepremium as opposed to providing you withMedicaid. Seniors with limited income mayqualify for Medicaid in addition to Medicare.

For patients facing a critical diagnosis,understanding all available options can

seem overwhelming. This information isprovided as a brief overview about issues

that are often complex.For further information, either call the

Patient Advocate Foundation at1-800-532-5274 or visit our website

www.patientadvocate.org.

Patient Advocate Foundationis dedicated to ensuring that all

Americans have access to healthcare.Case Managers are available to assistpatients affected by debilitating or lifethreatening illnesses by empowering

them to be able to make informeddecisions regarding their

healthcare options .

Patient Advocate Foundation421 Butler Farm Road

Hampton, VA 23666

Toll Free 1 800-532-5274 Fax: 757-873-8999

Email: info@patientadvocate.org

Internet: www.patientadvocate.orgPublication No. 10 7/2007 rev 4/2010

• ReferencesACS Hope Lodge; www.cancer.orgBlue Cross Blue Shield Association

www.bcbs.com/glossary.htmlCancer Prevention and Control

www.cdc.gov/cancer/nbccedp/Division of Facilities Compliance and Recovery

(DFCR); www.hrsa.gov/osp/dfcr/The Georgetown University Health Policy Institute,

"A Consumer Guide for Getting and KeepingHealth Insurance,"

www.healthinsuranceinfo.netHenry J. Kaiser Family Foundation;

kff.org/uninsured/index.cfmInsure.com; www.insure.comInsure Kids Now; www.insurekidsnow.govInvestorwords.comwww.investorwords.coml791Icatastrophic_coverage.htmlThe Leukemia and Lymphoma Society

www.leukemia-Iymphoma.orgNational Association of Health Underwriters

www.nahu.org/consumer/HRPGuide.htmNational Association of Hospital Hospitality

Houses, Inc; www.nahhh.org/index.phpNational Institute of Health (NIH); www.nih.govNational Patient Air Transport HELPLINE;

www.npath.orgNeedy Meds; http://needymeds.comNOLO; www.nolo.comPartnership for Prescription Assistance (PPA);

www.helpingpatients.orgPatient Advocate Foundation Co-Pay Relief

Program; www.copays.orgU.S. Department of Health and Human Services,

"Free Hospital Care, Nursing Home care andcare provided in other types of health facilitiesunder the Hill-Burton Program,"<www.hrsa.gov/osp/dfcr/

U.S. Department of Labor Employee BenefitsSecurity Administration, "An Employee's Guideto Health Benefits Under COBRA-TheConsolidated Omnibus Budget ReconciliationAct of 1986 (Revised September 2004);http://dol.gov

U.S. Department of Labor Employee BenefitSecurity Administration, "Health CoveragePortability-Health Insurance Portability andAccountability Act of 1996 (HIPAA) (October2004); http://dol.gov