Pathology Associates Of Lexington, P.A.
Pathology Associates Of Lexington, P.A.
Pathology Associates Of Lexington, P.A.
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        Obtaining third party coverage: 
      

One law firm website [HERE] has a one-page overview that can be a starting point prior to some of the detail on the current page, below. And, the eHealthInsurance website offers much comparative information. And, the US government launched a web site to help in 2010, HERE. I do not claim the following info to always be up-to-date or comprehensive. It is intended to open your eyes to possibilities.

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QUICK LINKS, THIS PAGE: Medicaid ; Medicare ; HSA ; employer type ; unisurable pool such as SCHIP ; Christian & other cost-sharing coverage ; copayment help ; medication assistance...all about Social Security DISABILITY (SSDI)...and many other topics, below:
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Otherwise, the page you are on now can be a starting point in the search for third party coverage or help. There are also some tips on how to fight denial of access to third party coverage. You can use the terms below in an internet search engine to learn more. Please e-mail me (address provided below) if you find any particularly good information resource or have other tips.

Health "insurance coverage" is a way that Americans have chosen to finance illness expenses. It is a way of mitigating financial risk. You or your employer (if you have group insurance through work) pays premiums to the insurance company in good faith that the company will assume the financial responsibility for the bulk of your medical expenses.

When determining what medical care can cost when you have coverage, there are two parts to be examined: your risks (copays, deductibles, out-of-pocket co-insurance maximums) and the insurance company's risks (the portion of your health expenses that they pay after you have paid your copay, deductible, etc.) The insurance company will try to limit their risks through use of negotiating "allowable" charges with the provider and have been known to try to shift this risk back to you or the provider through exclusions and specific handling of certain conditions.

Decades ago, insurance coverage amounted to coverage just for catastrophic expenses, such as a car accident. The individual budgeted for a certain amount of reasonably predictable health-related expense in the same way one might budget for auto repair. Benefits-minded folks pressed for more and more "first dollar benefits" coverage of lesser expenses before meeting one's deductible (wellness visits, routine screenings, immunizations, etc.). This component is more like prepaid medical expenses. But this leads to the thought process that the less a family has to consider costs, the more likely they will thoughtlessly & non-frugally buy health related items and services. Insurance lingo for this disconnect from financial risk is "moral hazard". At issue and seriously blurred, therefore, is personal and family "financial management" versus "risk management". The result of the blurring has been an administrative and paperwork nightmare and out-of-control charges & costs.

Here is a look at a few your options for insurance or help:

  • Individual/Family, personal, private commercial "indemnity insurance" that you buy yourself; this is a very unfriendly category to be in...you are all alone among "the sharks". Check the Life Happens web site & look at the "insurance 101" drop-down menu & choose "health" :
    1. Representation against the 900 pound giant:You can usually purchase this in two ways: through an agent or from the carrier directly. There is no difference in cost to you. Agents often represent more than one carrier and therefore can help you find the carrier and plan that is the best fit for you and your family. The agent can be expected to help you understand your coverage and sort through claims questions. Buying from the company directly is often less personal and can mean you'll have to carry the fight yourself.
    2. what plan type?: Check Coverage for All, the Insurance Information Institute, or the South Carolina Department of Insurance to see what each type of health insurance is and if a regular (commercial indemnity) insurance plan, a preferred provider organization plan (PPO), or a health maintenance organization plan (HMO) seems best for you. Ask friends about who insures them, what plan type they have and if are they satisfied. If you know anyone in the medical field who works with insurance, ask which carriers are prompt and thorough with handling claims and which carriers make the claims process more difficult.
    3. Become familiar with the different plan types available to you. Each insurance carrier is going to offer different plan types with different coverage. This is where having an agent can be an advantage to you. Two of the more familiar plan types are copay plans and high deductible plans. Some high deductible plans may qualify to allow you to open a Health Savings Account (HSA).
    4. Health Savings Account (HSA): available for coverage to non-Medicare patients, employed or unemployed, if you file federal income tax returns (a "smart money" web site explains; there are TWO components:
      • a high-deductible HSA-qualified health insurance plan (HDHP):
        1. plan conversion: one can convert from any low to any high deductible health insurance plan at any time (but not vice versa).
        2. there is only ONE annual deductible for an entire family.
        3. there is a maximum annual out-of-pocket expense.
        4. there is/isn't (?) a maximum life-time expense pay-out by the plan.
      • an HSA savings account (at fiduciary institution of your choice):
        1. an HSA lets you or your employer directly deposit money (as allowed by the IRS) for you in a tax-advantaged savings account in order to pay for qualified medical expenses; if age 55 or older, the insured can add "catch-up" savings contributions (as per IRS rules). Contributions can't be made once you are on Medicare.
        2. the account is YOUR property, fully portable from job to job or into retirement.
        3. the account can transfer at your death.
        4. it may also be used for expenses not covered by the insurance component (such as dental or vision care).

        HSA Bank is a good place to learn more about HSAs. Many banks and federal credit unions offer HSA savings accounts, as well. Please note that as of Dec. 31, 2003, laws converted all medical savings accounts (MSAs), which were then only available to self-employed individuals, to HSAs. This gave all individuals the opportunity to pay for their medical expenses with tax-free savings.

    5. getting idea of cost: you might try an on-line quote service to get some ideas and to see information and definition files, etc.
    6. a cheaper group way for employees without health insurance: Check with your hobby or other association, employer's business association, club, fraternal, or other organization for group insurance. Your employer (who may not be able to afford health insurance coverage benefits for you) may be willing to pay for your annual membership in an organization with a member's group health insurance plan (I'd guess that practically anyone might join the Federation of American Consumers and Travelers and obtain their group insurance ). Those aged 50 or older can join liberal AARP or its conservative competitor, USA Next.
    7. a cheaper group way for the self-employed: National Assoc. for the Self Employed
    8. another way: The Defined Contribution Alternative is a new way for individuals to pay premiums and have control over where they obtain services; check Destiny Health at CDHCA as an example.
    9. SimpleCare: simplified catastrophic insurance for those willing to pay cash for negotiated 30-50% provider discounts!
    10. Prepaid doctor: You maintain 3rd party insurance or Medicare (high deductible insurance for catastrophic care seems smart) and prepay for a doctor's care. It is said that the average USA primary care doctor can handle alone about 2500-3000 patients for a year. As insurance companies press fee payments lower and all other expenses increase for the doctor, he/she must be ever more in a hurry to handle each patient visit as briefly as possible. MDVIP is a type of medical practice where checkups and doctor visits are handled by a particular doctor who limits himself/herself to 600 patients, each of whom prepays for a year of attention (including house calls) for $1500 per year (less than a cigarette smoker spends per year on their habit).
    11. state high risk pools: S. C. Health Insurance Pool for individuals otherwise uninsurable due to pre-existing illnesses 800-868-2500, ext. 42757 (check with your state's Dept. of Insurance).
    12. Health insurance exchange: the 2010 Obamacare law set the stage for these potentially government sponsored plans which each state may inact (Mass. has had one since 2006 & Utah since 9/2010).
    13. Hospitals and real emergency rooms: in an emergency in the USA, the requires that you be helped. If you have no coverage, most will out you on a payment plan.
  • Individual insurance coverage through a "group": I'd guess that practically anyone might join the Federation of American Consumers and Travelers and obtain their group insurance ; or check with hobby or other association, employer's business association, club, fraternal, or other organization for group health insurance.
  • AAA & other groups with discounts: AAA has (as of 2011) brand-name medication discounts for AAA members at 1000s of pharmacies [here].
  • Employer (company/independent contractor/self-employed) provided health insurance deals (many Americans get coverage this way, and your employer's "company benefits representative" is sort of an indirect "agent" to help in fights with the insurance company):
    1. Employer-sponsored conventional insurance: group health insurance using regular indemnity, HMO or PPO. In many cases the employer and employee share the cost of the premium, though the employer can choose to contribute only toward the coverage of the employee, which means that coverage of a spouse/family is entirely the responsibility of the employee. The employer may offer payroll deduction, allowing the employee to pay for their insurance with pre-tax dollars. Many employers offer tiered plans (2 or more types) and the lowest-cost ones may have a LOT of uncovered services (such as pathology or lab or radiology fees). You should read your outline of coverage carefully, noting limitations in coverage.
    2. Employer-sponsored HSA: These work in the same way as they do on an individual basis, above. A tax-favored savings account is linked with high-deductible insurance, and qualified medical expenses may be paid from this account. Any unspent balance rolls into the next year, and employee owns the account. HSAs are portable, meaning that even if the employee leaves the company, they own their HSA and can associate it with a new high-deductible, qualified plan. Plan notes for our medical group's interest.
    3. Employer-sponsored, payroll deductible Flexible Spending Accounts (FSA) ("cafeteria plans"; IRS Sect. 125 plans): with a health-expense component, it allows you to put up to $5000 per year of your paycheck into an account for expenses within the deductible portion of your company's health insurance plan. The key difference between an FSA and an HSA is that you have to use the money you deposit into an FSA that year or you lose the money. Therefore it is important each year to deposit only as much money as you intend to use on medical expenses. Until mid-2003, you had to "front" out of pocket money to pay for the medical expense; then file claims for re-imbursement from the FSA. Now, it is possible to link your FSA with a debit card (an example is Metavante Healthcare Payment Solutions) so as to avoid the need to "front" the payment. The FSA-POP variant (premium only plan) of this plan allows employees to use the FSA to pay their health insurance premium (an example is Med-i-Bank)...a potential way to begin your company FSA!
    4. Employer-sponsored "consumer driven" health plan (defined benefit account) (Personal Health Account): refers to defined contribution health plans under which the employee receives a fixed dollar contribution from an employer to choose among various plans. An employee who chooses a benefit-rich plan may have to contribute a significant amount of his own money in addition to the employer contribution, whereas an employee who chooses a less benefit-rich plan would pay less of his own money. Some say this is managed care with a high deductible. Definity Health is a company offering this type of plan (others are Aetna, Humana, & Lumenos). It is somewhat like the HSA...any unused contribution can roll into next year...but without benefits being able to accumulate in the account above $4000...the size of the deductible in the associated health insurance policy (employer can put about $1000 per year single and $2000 per year family). But check changes in limits and other factors at Consumer Driven Health Care website.
    5. Employer-associated "captive insurance company": the company does its own insuring...see the Riskman International's notes 
    6. Employer-associated Health Re-imbursement Account/Arrangement (HRA): an arrangement where the employer reimburses an employee for qualified health expenses. This does not need to be paired with catastrophic insurance coverage. This account is owned and funded by the employer. There is no cash value earned by the employee, and it is not portable when the employee leaves the company. Funds from an HRA may be used to pay for the premiums of an individual health plan if the employer doesn't offer group insurance. An employee's unused moneys from one year can be carried over into the next year, & the Base Group explains the HRA as they offer it.
    7. Health insurance exchange: the 2010 Obamacare law set the stage for these potentially government sponsored plans which each state may inact (Mass. has had one since 2006 & Utah since 9/2010).
    8. Cash needed for the high deductibles: There are some lab programs and medical practices for cash-paying patients.
      • Lab: In the "midlands" of S. C., check Lab Tests on Demand.
      • Physician practices: you may be able to get services through a bid process at such as MediBid.
      • Meditourism: cash discounted medical services outside of the USA; here is a guide source.
      • On-line pharmacies: Be extremely careful!!! On source notes that, in Canada, some safety comes with being sure that the source is a current certified member of the Canadian International Pharmacy Association.
  • If you lose your job: if you had employee health coverage with the employing company, you can continue coverage 18 months under COBRA (though expensive, you should almost always chose this if you can so that insurance does not lapse & cause you to have a new 1 year waiting period for pregnancy or prior medical problems) & use it as a temporary bridge while you search for both a new job and health insurance coverage. This will depend on your group; ask your group benefits coordinator about the specifics of your group's COBRA continuation.
  • Medicaid in S. C.:
    1. Regular Medicaid: this is the fee for service type; ask specifically about the non-medical home, non-managed care, "regular medicaid" (I find very little on-line about this coverage that can cover you with any provider who "accepts medicaid").
    2. Managed Care Organizations (MCO): choices HERE.
    3. Medical Home Network (MHN): choices HERE.
  • Uninsurable: if health issues are such that no insurance company will cover you, many states have health insurance pools (in S. C., SCHIP).
  • CHAMPUS: US military.
  • Health Cost Sharing Organizations or Ministries: these (1) require "share" payments each month at about half the cost of ordinary insurance & (2) are not insurance companies & (3) tend not to cover ongoing pre-existing conditions. (4) It is not a contractural arrangement. (5) It is for professing Christians who agree not to smoke, not to use illegal drugs, & not to have sex outside of marriage. (6) It is Christian "strangers helping strangers" in ways similar to an Amish barn raising that can be done in a weekend (rather than 3-4 months) as many pitch in. HERE is their association.
    • The Christian Care Ministry: a 501(c)3 non-insurance, membership, Florida based cost-sharing cooperative since 1993 (the largest Christian health sharing organization), using Medi-Share. To qualify, you need (1) a verifiable Christian testimony, (2) agree that Believers are to bear one another's burdens, (3) understand that pre-existing conditions prior to joining Medi-Share are not elligible & that diabetes & obesity might be disqualifying, and (4) are living a healthy, biblical lifestyle that includes abstaining from smoking, drug abuse, excessive drinking, and sex outside of marriage.
    • Samaritan Ministries International: Illinois based.
    • Christian Healthcare Ministries: Ohio based.
  • Copayment Foundation Charities: these can help the underinsured and uninsured.
  • Free or very low-cost clinics: a listing in all states, by city.
  • Free or low-cost mammograms and Pap smears: National Breast and Cervical Cancer Early Detection Program and Best Chance Network (BCN) in S. C.
  • Family coverage & assistance mix: If a spouse has a chronic condition when you went on COBRA, above, you may find that your employer had a COBRA plan that allows that spouse to continue with COBRA cheaper than in your new coverage. your family may be in a financial bracket where you have some adult coverage but could save money by qualifying your children under the SCHIP programs. State Children's Health Insurance Program (SCHIP or CHIP) for children (age 18-19 or younger) of those families who can't qualify for Medicaid but who can't afford private health insurance (8/2003 you may qualify with family income up to $36,000 per year). See this website as to some overall info HERE.
    1. some qualifying info in S. C..
    2. link listings by state.
    3. Partner's for Healthy Children in South Carolina.
    4. Healthy Connections Kids (HCK): this program in S. C. is administered by the S. C. Dept. of HHS.
    5. Health insurance exchange: the 2010 Obamacare law set the stage for these potentially-government-sponsored plans which each state may inact (Mass. has had one since 2006 & Utah since 9/2010).
  • All About Retiree Benefits, Eldercare, various Assistance, including on-line application forms [HERE].
  • Medicare, check here. (usually for those 65 or older). You must enroll; The federal gov. funds a nation-wide network of free State Health Insurance Assistance Programs (SHIPs) which can help you. There are 5 items:
    1. Part A: premium free if you had a sufficient work history & thereby USA-government provided...this is hospital & skilled nursing homes.
    2. Part B: you personally pay (or it is extracted from your social security payment due you) the US government for this to cover doctor bills & outpatient lab, radiology, and other tests.
    3. supplimental ("medigap") coverage: this is federally standardized coverage you personally buy from insurance companies or membership organizations to help cover the 20% co-pay risk in the Part B.
    4. Part C/Advantage: this is an alternate to Part B, if you prefer, and bought as one of many not-federally-standardized Advantage Plans through insurance companies.
    5. Part D: this is the prescription-drug coverage insurance you may buy through Medicare or qualify (if "credible coverage"...as good as Medicare).
  • Medication assistance programs: senior citizen prescription drug programs such as South Carolina's SILVERxCARD program (created in 1999), serving 50,000 South Carolinians as of Sept. 2004 (about 70% of funding from Medicaid). It is federally permitted to continue in S. C. through the end of 2007, if DHEC agrees and is available to those individuals making $1551/month or less and couples making $2082/month or less. Will be replaced by Medicare drug card in 2006.
  • Other care for elderly: Palmetto SeniorCare.
  • For those with low financial means:
    • Medicaid. In the first paragraph on this medicaid webpage, click on "select a state" to find details of Medicaid in your state.
    • If you just don't have coverage, see the Cover the Uninsured promotion website & scroll to the "state guides" and click on that and select your state & read about the programs available.
    • US Office of Family Assistance may have some ways to help.
  • Disability...Social Security and/or Medicare
  • for those having trouble getting access to health care: The Center for Patient Advocacy in McLean, VA (800-846-7444) [website disappeared as of Sept. 2004].
  • Genetic issues can be reviewed in certain areas of the Genetic Alliance  website.

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e-mail any tips to poptop43 @yahoo.com (posted Aug. 2001; latest addition 28 February 2013)

 
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