A privately purchased insurance plan that pays for medical care including hos-pitalization, surgery, doctor visits, and related services. Each medical insurance plan has specific coverage requirements; many plans have copay-ments and deductibles (amounts the insured person pays out of pocket). Most medical insurance plans provide at least partial coverage for prescription drugs; some do not. Medical care is the most costly consumer expense after housing in the United States. Although medical insurance rates may be $3,500 to $7,000 a year or more, depending on the plan’s coverage, a single surgery such as an emergency appendectomy (removal of an infected appendix) costs as much or more. So can a year’s worth of anti-parkinson’s medications.
If there is a single rule that applies to all medical insurance plans, it is to know the plan. Know the benefits, limitations, restrictions, exclusions, copayments, deductibles, grace periods (if any) for premium payments, cancellation procedures, and renewal requirements. Medical insurance complex is a legal contract that deserves careful consideration and thorough review. Yet most people know little more about their medical insurance than its rates and copayments. Even for a group plan through an employer, request a copy of the full medical plan from the employer’s benefits coordinator or human resources department. A summary of benefits or benefits brochure, which is what most employers distribute to employees, is not adequate for determining coverage of health conditions as complex as Parkinson’s disease. When medical insurance does not cover a service it is the insured person’s responsibility to pay the costs, which can quickly become substantial.
Kinds of Medical Insurance Plans
There are a number of different kinds of medical insurance plans. Most fit into one of the following general benefit structures. Some combine structures, such as participating provider plans that also offer fee-for-service coverage (usually at a reduced benefit level). A person always has the right to go outside the benefit structure for care, such as to see a specialist that the plan does not cover, at his or her own expense. It is important to know the ramifications of this, however. If that specialist orders tests, the insurance plan may not cover those tests. Always obtain clarification from the insurance company before going outside the plan’s network.
• Managed care organizations or structures: Many medical insurance plans require people to use designated provider networks to receive benefits. Typically a primary care physician oversees a person’s medical care and must authorize any specialty referrals. The most common structures are health maintenance organizations (HMOs) and preferred provider organizations (PPOs). A few HMOs across the country are staff model HMOs, meaning they own the hospitals, medical centers, laboratories, and other facilities and hire the providers (doctors, nurses, and other health care professionals). PPOs are community providers who have signed agreements with the insurance company to accept specified payment or reimbursement and to follow the insurance company’s procedures and guidelines regarding medical services. Managed care plans may refuse to pay for care provided outside their networks; it is essential to know the requirements for out-of-network and out-of-area (such as when traveling) coverage.
• Fee-for-service plans: These medical insurance plans, sometimes called major medical plans, pay set fees for covered services, and the insured person must pay the difference between the benefit amounts and the charges billed. Typically there is a limit or cap on the total out-of-pocket expenses a person may have to pay in a year. With such a plan, a person often can self-refer to a specialist, if the specialist will accept patients without a referral (many will not).
Obtaining or Maintaining Medical Insurance
Most people who have private medical insurance have it as an employment benefit; the insured person pays part or all of the monthly premiums. Such group medical insurance plans typically offer broad-based coverage. The person and his or her family, if applicable, remain eligible for the plan as long as the person remains employed. There are extensions of coverage and conversion options when ending employment; these generally require the person to pay the full premium, are time-limited, and can affect a person’s right to obtain individual medical insurance in the future (see the discussion of HIPAA in the next section). As well, they may apply only under specific circumstances and may not apply if the person retires. Individual medical insurance, which a person purchases independently of employment, typically costs more and covers less. State laws regarding individual medical insurance vary widely, so coverage and rates can differ significantly. Many states offer subsidized medical insurance (different from mEdicaid) for people who meet certain income and other criteria.
Nearly all medical insurance plans renew annually. Benefits, exclusions, restrictions, and rates can, and often do, change at each renewal period. It is important to review the plan carefully at each renewal period. Some plans continue a person’s enrollment unless the person files paperwork to withdraw; other plans require new enrollment documents with each renewal period.
Health Insurance Portability and Accountability Act of 1996 (HIPAA)
Important federal legislation is the Health Insurance Portability and Accountability Act of 1996 (HIPAA), which establishes guidelines that medical insurance companies must follow. HIPAA provides important protections for people who have serious or chronic health conditions such as Parkinson’s disease. It prevents insurance companies from
• Denying enrollment on the basis of medical conditions (under any circumstances for group medical insurance plans and under specified circumstances for individual medical insurance plans)
• Selectively refusing to cover a particular medical condition (exclusions and limitations must apply to all people who have the same plan)
• Selectively raising one person’s premiums
• Denying renewal of the medical insurance plan because of medical conditions
For detailed and updated information about how HIPAA applies in specific situations, contact the U.S. Centers for Medicare and Medicaid Services (CMS):
U.S. Centers for Medicare and Medicaid Services
(CMS) 7500 Security Boulevard Baltimore, MD 21244-1850 877-267-2323 (toll-free) TDD 866-226-1819 (toll-free) http://cms.hhs.gov/hipaa/online/
Most states have additional regulations and consumer protections under state extensions of HIPAA, particularly for individual medical insurance plans; the state’s office of the insurance commissioner can provide additional information.
Medical insurance is essential for the person with Parkinson’s. However, a person who does not have medical insurance at the time of diagnosis may have difficulty finding a plan that will cover expenses related to Parkinson’s. Local Parkinson’s disease support groups and the American Parkinson’s disease association can provide information about insurance companies that offer good medical plans for people with Parkinson’s disease.
People who are diagnosed with Parkinson’s disease while they are still employed often consider early retirement. However, medicare eligibility does not begin until age 65 (with limited exceptions for disability). This restriction can create a significant period during which the person will need a private medical insurance plan. Some employer-sponsored group plans have conversion options; the benefits coordinator can explain these if they exist. These can be expensive and time-limited, although they may be adequate to cover the interval between retirement and eligibility for Medicare.
The benefits coordinator, or retirement planning coordinator if the employer has one, often can help identify other medical insurance options. These may include coverage through a spouse’s group medical plan, if the spouse is employed; enrollment in a plan through a membership organization; or purchase of an individual medical insurance plan. An independent insurance agent also can provide advice and recommendations. As well, it can be helpful to talk with other people who have Parkinson’s disease who have followed a similar process.
Restrictions and Exclusions
All medical insurance plans have restrictions and exclusions. It is crucial to know what these are and how they apply to specific situations. There are circumstances in which an insurance company may issue an exception; always obtain documentation of the exception, as well as any coverage clarifications, in writing. Common limitations include:
• Preexisting conditions and coverage waivers: Some medical insurance plans exclude coverage for preexisting conditions medical conditions present at the time the plan begins (or in the previous six months). A preexisting condition exclusion is temporary but can remain in effect for as long as a year. During this time, the medical insurance plan will not pay for any services related to the condition. Some states permit insurance companies to sell individual medical insurance plans with waivers that permanently exclude coverage for preexisting conditions (employer-sponsored group medical plans cannot do this); these are not a good option for the person with Parkinson’s disease as medical needs related to Parkinson’s increase over time.
• Preauthorization: Most medical insurance plans require advance approval of any major procedure, whether diagnostic or therapeutic. Doctors’ offices generally know what services require preauthorization, but it is the insured person who is ultimately responsible to pay for the expenses the medical insurance plan does not cover. It is prudent to check with the insurance company before having any scheduled surgery or hospitalization. Some medical insurance plans also require preauthorization or notification to receive care from providers (sometimes including urgent care and emergency care) who are not members of the plan’s network, as when traveling.
• No coverage for investigational or experimental treatments, including drugs: With rare exception, medical insurance plans do not pay for investigational or experimental treatment. Investigational treatments typically are part of clinical research studies; in those cases the study should cover all expenses related to the condition under investigation. Doctors sometimes recommend using approved treatments in ways other than those for which they are approved. This is a gray area as far as insurance coverage goes.
• Very limited or no coverage for skilled nursing facility (SNF) and long-term care: Many private medical insurance plans provide limited coverage for admission to a skilled nursing facility (SNF). There are often strict qualifications including preauthorization, and necessities such as prescription drugs may not be covered. Medical insurance sometimes pays for certain long-term care services provided on an outpatient basis, such as home health care, but does not pay for residential care in a long-term care FACILITY.
The medical insurance plan’s benefits and procedures for specialty care are particularly important for people with Parkinson’s disease. Some managed care plans may have limited access to specialists such as neurologists or may require a referral from a primary care physician each time the person consults a neurologist.