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Are You Taking Advantage of The New Health Insurance Appeals Process?

Wednesday, June 15th, 2011

One of the big advantages of the Affordable Care Act (a.k.a. the healthcare reform bill) is that millions of Americans who once had no recourse when their insurers turned them down for coverage, now can appeal. Insurance company turns you down for a transplant? Appeal. Says no to a life-saving procedure? Appeal. Insists that you have to pay for something you believe is covered under your policy? Appeal.

And your appeal won’t be decided by the same administrator who turned you down in the first place. Under the new healthcare reform law, health insurance appeals are decided by an independent decision-maker, one who has no financial stake in the outcome.

This provision can be a lifesaver … but only if you know about it and act on it within the 180-day timeframe permitted.

According to Kaiser Healthcare News:

The provision took effect for most plans Jan. 1. But in response to self-insured plans’ concerns about being able to meet some of the requirements, the government said it wouldn’t require the plans to tell members about their external appeals rights until plan years beginning after July 1. Since most plans start their new year in January, that means they won’t have to notify members about their right to external appeals and how to file them until next year.

However, the government isn’t granting enrollees more time to file appeals, said an official at the Department of Health and Human Services, who spoke only on the condition of not being identified. Patients have 180 days from the date of initial denials to file internal appeals to the plan. If the appeals are rejected, they then have another four months to appeal to outside arbiters.

If nobody tells patients about their rights, this provision, in other words, might not be discovered by the people who need it most until it’s too late.

So, I’m urging you to link to this post wherever you can: Facebook, Twitter, Reddit, any and all social networks. Explain the need to be informed. Tell your friends and family: you have a right to appeal. For some, it can be a matter of life and death.

Don’t let the chance slip away.

– Yvonne S. Thornton, MD, MPH

When You Can’t Buy Health Insurance, at Any Price

Monday, February 21st, 2011

As you might already know, I’m a staunch advocate for access to health care, and cheered when health care reform became the law last year. We need the opportunity to stay well and keep our families well, and we need to be able to afford medical care when things go wrong. As a mother and a physician, I’ve seen firsthand how imperative this is.

There are those who say we should repeal the recent landmark health care reforms that Congress passed last year. But that would mean that some people would be shut out of health care completely. Some seem to believe it’s just those who are too poor to afford health insurance, or who can afford it but choose not to buy it, who go without. Those are faulty assumptions, as this op ed by the co-founder of Palm Computer, who was denied insurance before the new law passed, shows:

It never occurred to me that we would be denied! Yes, we had listed a bunch of minor ailments, but nothing serious. No cancer, no chronic diseases like asthma or diabetes, no hospital stays.

Why were we denied? What were these pre-existing conditions that put us into high-risk categories? For me, it was a corn on my toe for which my podiatrist had recommended an in-office procedure. My daughter was denied because she takes regular medication for a common teenage issue. My husband was denied because his ophthalmologist had identified a slow-growing cataract. Basically, if there is any possible procedure in your future, insurers will deny you.

If a woman with $millions couldn’t get approved because of a corn on her toe, what would happen to the average woman, or a child, with a more serious issue if health care reform were repealed?

We need to keep ourselves informed about what’s really at stake. And, trust me, there’s a great deal at stake. If health care reform is repealed, we go back to the days when life-saving care is denied to people who can’t pay the costs—oftentimes, hundreds of thousands of dollars—out-of-pocket. We go back to seeing our kids kicked off our policies when they’re just out of high school and don’t yet have jobs that offer health insurance. We go back to denials for pre-existing conditions as tiny—and ludicrous—as a corn on the toe. Or acne. Or depression. Nevermind more serious illnesses.

We can’t go back. Look at how far we’ve come. Please, be as informed as possible about your new rights under health care reform. You can find most of the information you need at this website set up by the government to guide you through your options and your rights.

– Yvonne S. Thornton, MD, MPH

All your questions answered on how Healthcare Reform will affect you

Thursday, September 23rd, 2010

You might have read that as of  today, September 23, 2010, consumers will have several new rights when dealing with health insurance companies:

  1. Children can no longer be turned down for health insurance due to pre-existing conditions.
  2. Your insurer can no longer cancel your health insurance policy if you get sick.
  3. Your insurer can no longer charge you a co-pay for preventive care or tests such as mammograms and colonoscopies.
  4. If you have a medical emergency and need to go to an out-of-network hospital, insurers can’t charge you additional fees.
  5. You won’t need a referral from your primary care physician to visit your Ob-Gyn.
  6. Insurance companies can no longer cap the dollar amount of lifetime benefits available to you for essential medical care.
  7. You now have a right to appeal to an outside authority if your insurer denies a claim.
  8. Your adult children can stay on your health insurance policy up to the age of 26.

One thing the above should tell you: you’ve lost your last excuse for putting off that mammogram (make an appointment today, if you haven’t yet).

These changes are hugely valuable – but most people don’t yet know about them.

And the above are just the beginning. The Kaiser Family Foundation has one of the most comprehensive explanations I’ve seen of just how healthcare reform is likely to affect you and your family. And while you’re at the website, check out the animated video for an entertaining, thorough explanation of your expanded rights under the new legislation. It covers just about every question you might have.

– Yvonne S. Thornton, MD, MPH

Pre-existing condition? No longer a problem.

Friday, July 9th, 2010

After all the hoopla, once healthcare reform was signed into law earlier this year, it didn’t immediately seem like much had changed. Most of the provisions of the new healthcare bill aren’t slated to take effect for a few years yet.

But there’s one provision, an all-important one for people who have been denied health insurance in the past, that could be a lifesaver.

And it takes effect this summer.

You can now get health insurance – good comprehensive coverage – if you’ve previously been turned down due to a pre-existing condition. Your new insurance will cover that pre-existing condition along with your other medical needs. Perhaps best of all, according to law, the premiums for this insurance must be affordable. You should pay about what anyone else your age pays, regardless of health.

Depending on the state where you live, the insurance plan will either be run by the state or federal government. Go here to find out about how to apply in your state.

So, if you have been denied insurance, or denied insurance for your pre-existing condition, and have been without any health insurance for six months or more, this is for you.

Take advantage. And here’s to your good health.

– Yvonne S. Thornton, MD, MPH

Think you don’t need health care reform if you’re covered by your employer? Wrong.

Tuesday, February 16th, 2010

You may have heard that Anthem-Blue Cross proposed raising its rates for individual health insurance policies by as much as 39 percent in California. President Obama and Secretary of Health and Human Services Kathleen Sebelius have both decried this outrageous hike. A recent report from the Associated Press shows that similarly huge rate hikes are coming to individual policies in many states including Maine, Kansas, Oregon and Indiana.

“You’re going to see rate increases of 20, 25, 30 percent” for individual health policies in the near term, Sandy Praeger, chairwoman of the health insurance and managed care committee for the National Association of Insurance Commissioners, predicted Friday.

But you might think that this has nothing to do with you if you’re employed by a company that provides you with health insurance. Unfortunately, all of us are affected, no matter where we get our insurance.

The Anthem-Blue Cross increase is the harbinger of things to come in employer-provided policies as well.

Last week, I heard from someone whose employer had to switch from a comprehensive policy to bare bones insurance because the insurer raised the company’s group rate by about 30 percent. So now, instead of offering employees a policy that covers just about anything, from a broken ankle to a liver transplant, the company will offer its employees a policy with an annual cap of just $25,000.

That’s employer-provided insurance that’s in danger now. And that means that more Americans are at risk of having either no insurance or inadequate insurance when a medical emergency strikes.

As a doctor, I am well aware of the high cost of medical care and can assure you that a policy with a $25,000 annual cap won’t cover much if you need hospitalization. I’ve dealt with that reality, not just as a physician, but as a mother. As I wrote on this blog before, when my daughter had to be hospitalized a few years ago, we learned too late that her school-provided policy had a $25,000 annual cap. Lucky for Kimmie that her parents are both doctors and could afford to pay the tens of thousands of dollars in hospital and medical bills that her insurance didn’t cover.

What would you do if one of your loved ones needed medical care and your insurance was inadequate?

This is no longer an issue for the uninsured. It’s an issue for us all. Please tell your Senators and Congressional representatives that you support health care reform. The life of someone you know, maybe someone you love, maybe your own, may depend on what happens next in Washington, DC.

– Yvonne S. Thornton, MD, MPH

Why Health Care Reform Is Essential to You and Your Family – Even if You’re Insured

Thursday, January 28th, 2010

Last night, President Obama, in his State of the Union address, reminded us why we need real health care reform.

First, I’ll quote a few of the points the president made and then I’ll explain why it matters to each of us, currently insured or not:

“The approach we’ve taken would protect every American from the worst practices of the insurance industry. It would give small businesses and uninsured Americans a chance to choose an affordable health care plan in a competitive market.  It would require every insurance plan to cover preventive care.

“… It would reduce costs and premiums for millions of families and businesses. And according to the Congressional Budget Office – the independent organization that both parties have cited as the official scorekeeper for Congress – our approach would bring down the deficit by as much as $1 trillion over the next two decades.”

When the president spoke of the insurance companies “worst practices” he didn’t elaborate. But it’s those practices that make us all, insured or not, vulnerable, and in need of reform. Too many Americans believe that they have great health insurance – right up to the moment when they get sick and find that their insurance won’t cover their medical bills.

Recently, one of the organizations advocating on behalf of health care reform shared the case histories of numerous people who, although insured, were unable to get their medical bills paid when they got sick. The following few cases are among dozens of similar stories. If we don’t think it can happen to you, you’re wrong. I speak from experience. Although I’m a doctor, when my daughter became ill, her insurance refused to cover all her medical costs and I had to pay tens of thousands out of pocket.

  • An AT&T worker from Arkansas was in a coma for three weeks after a 2004 horseback riding accident. She and her husband had to pay more than $200,000 in medical bills because UnitedHealthcare wouldn’t cover her emergency surgery.
  • A Realtor from Delaware, has a health care plan that forces her to pay for her cancer care “out of pocket.” She has turned to getting her chemotherapy medication from India in order to afford it.
  • A minister from Tennessee has almost $175,000 in medical debt due to his wife’s muscular disorder. The family had health insurance through his wife’s job as an insurance claims adjuster, but the health insurance would only cover 14 days of her 91 days in intensive care.

Don’t let anyone tell you that if you’re insured, you don’t need to support health care reform. As the above cases illustrate, this affects us all. While there is no longer any chance of passing a new bill through the United States Senate, the House can vote for the Senate bill that passed over Christmas eve now and make changes over time.  It may be our last chance for reform in a generation. Please call your Congressperson today and remind him or her what’s at stake.

– Yvonne S. Thornton, MD, MPH

The best Christmas present the Senate could give us: Health care for all

Thursday, December 24th, 2009

Despite months of bluster and disinformation from those who hope to maintain the status quo, 60 U.S. senators came together this Christmas Eve morning and voted to make health care available to virtually all Americans.

The House had passed its version of health care reform months earlier. Now the two legislative bodies will have to come together and agree to a blended version.

That blended version almost certainly won’t have a public option because it would require 60 votes in the senate to get one. But here’s what we can be assured of getting in any final combination of the two bills:

  • Insurance companies will have to cover everyone – you can no longer be turned down due to pre-existing conditions.
  • Insurance can’t be snatched away from you via “rescission” when you get sick, i.e., voiding the policy when you need it the most.
  • There will be limits on how much more insurers can charge you as you get older.
  • Your insurance won’t run out when you need it due to annual or lifetime caps.
  • Most lower and middle-income people will get subsidies to help pay for insurance.

For those who say the senate bill doesn’t do enough, remember that getting this passed was a Herculean task. This is just the start of reform. Over the years, our lawmakers can continue to improve the bill, just as they’ve done with Social Security and Medicare. This is a long overdue beginning to regulating the health insurance companies, which have been given carte blanche for so many years.

The Centers for Disease Control recently reported that 58.4 million Americans were uninsured for at least part of the year and almost 32 million had been uninsured for more than a year. The situation will only get worse if we do nothing. As President Obama is fond of saying, we can’t let the perfect be the enemy of the good. This is a good bill. And it’s the best present that the U.S. Senate could give us this holiday season.

Merry Christmas to all.

– Yvonne S. Thornton, MD, MPH

Halfway to realizing real health care reform

Wednesday, November 11th, 2009

This past weekend, in the House of Representatives, our congressmen and congresswomen came together to pass a bi-partisan bill. In doing so, they took the first step toward ensuring that all Americans have access to health care when they need it.

If a final bill passes that includes the provisions of this bill, here’s what we can all look forward to:

* No more lifetime or annual caps on how much treatment health insurance will pay for. This is so very important for men, women and children with chronic illnesses, who often see their claims for care denied, just when they need it most.

* No more denial of insurance coverage for pre-existing conditions. As of right now, some health insurers consider having had a cesarean section a “pre-existing condition.” They deny claims to victims of domestic violence, calling it a “pre-existing condition.” Even perfectly healthy babies who are a bit chubby have been turned down by health insurers who claim their weight is a “pre-existing condition.”

* Adult children would be allowed to remain on their parents’ policies until age 27.

* Seniors on Medicare would pay less for prescriptions.

* And all would get a genuine choice of health insurance options, available from both health insurance companies and a government-administered plan (the public option).

None of us should have any illusions that this first step toward making health care affordable and available to all will make the next steps any easier. Powerful interests, particularly those of health insurance companies, will fight all that much more aggressively to prevent the senate from passing its own version of reform. Health insurers’ profits are as high as they are because they get to cherry-pick who they will and won’t cover; because they can refuse to provide care after someone has reached the annual or lifetime coverage cap; because they can call almost anything a “pre-existing condition.”

Through misinformation campaigns, spread by surrogates, these powerful special interests have done all they can to frighten Americans into believing that health care reform will be bad for them and for America. The misinformation often mirrors that which was spread back in the 1960s in an attempt to prevent Congress from passing Medicare.

As a physician who has seen, firsthand, how the lack of health insurance can devastate families, I know that we must fight back aggressively against the special interests. We must become informed about the realities of health care reform and help our friends and families understand the difference between information and misinformation.

This opportunity to provide health care for all may not come again for many years if it doesn’t succeed now. And if it fails today, next time, the fight will be even harder and will stand less chance of success.

As a doctor, a woman, and a mother, I urge our senators, no matter their party affiliation, to stand with our families and help us protect them when they are most vulnerable. And I urge my readers to contact their senators and tell them that nothing is more precious than health – and nothing more important than passing reform so that families can get the help they need when they need it.

– Yvonne S. Thornton, MD, MPH

Is baby fat a “pre-existing condition? Really?

Tuesday, October 13th, 2009

You may have read the news that a family in Colorado was told their 4-month-old son would be denied health insurance by Rocky Mountain Health Plans because of a pre-existing condition: he was too chubby.

The child in question, baby Alex Lange, weighs just 17 lbs and is 25 inches long. That puts him in the 99th percentile according to the CDC but his pediatrician says the baby is perfectly healthy.

Although the insurance company’s spokesperson, Dr. Douglas Speedie, agreed that a baby can be healthy at little Alex’s weight, he said that the line has to be drawn somewhere. “It’s a calculation based on height, weight, and a fudge factor.”  But he also said “We’d like to see health care reform so that these things go away.”

Just think of that for a minute. Why does a health insurer claim there is a pre-existing condition where none exists? And if an insurer acknowledges that this is a flawed decision-making process, why doesn’t it act on its own to make “these things go away”? Does this make sense to you?

Me neither.

And that illustrates why we need health care reform. Right now, insurers can claim people have “pre-existing conditions” that they don’t actually have, and make other arbitrary decisions to deny people care. That must change and insurance companies will not change on their own … well, except in cases where their decisions are so ridiculous that they make the nightly news.

In baby Alex Lange’s case, the negative publicity convinced the insurer to reverse its decision. But the reason that Alex’s story got so much attention is that his daddy works for the NBC TV affiliate in Colorado that broke the story.

Most other people just get stuck with the insurance company’s arbitrary decisions.

– Yvonne S. Thornton, MD, MPH

Health care reform will save the U.S. $250 billion per year says Institute of Medicine

Thursday, September 17th, 2009

No one should die in America for lack of health insurance. Yet so many people do – one every thirty minutes.

We know we have to change this. It’s one of the great moral issues our country faces. Yet, there are those who say, we can’t afford to cover everyone. I can’t fathom that argument. I believe that all deserve the right to life-saving treatment.

So I was happy to learn that we will soon have an economic argument as well as a moral argument to support making health care available to all.

The Institute of Medicine is about to release a study that reportedly found that, some years after reform is instituted, we  may save up to $250 billion per year over what we’d pay if we did nothing.

That gives us every reason to reform health care and no excuses not to. The moral imperative is obvious, at least to me, as a doctor who has treated both the very poor and the very wealthy. The economic argument should counter those who want to do less or nothing at all.

To save lives (and even, we now learn, to save money), it’s time to provide no loopholes, no fine print, real, affordable health care coverage for all.

– Yvonne  S. Thornton, MD, MPH

UPDATE: The above figures, showing that one person dies every 30 minutes due to lack of health insurance, are from The Institute of Medicine statistics of 2002. A new study, just released today by Harvard Medical School researchers, shows that it’s even worse than that: today, one person dies every 12 minutes due to lack of health insurance.