Health Insurance Tips

Having insurance does not mean all treatment costs will be covered

Insurance plans can vary a lot in what they cover, which can make it hard to understand what your loved one’s policy will pay for. You may feel like a detective trying to sort through health insurance details and figure out how to access benefits. Unfortunately, not all services a person needs may be included in an insurance plan.

Be sure to find out what your plan does and does not cover. You can get a full copy of your loved one’s insurance policy and learn its rules, limits, and coverage. Staff at the hospital or rehabilitation facility may be able to help explain your policy and offer guidance on getting services approved. If your insurance does not cover everything you or your loved one needs, you may need help paying for medical care, rehabilitation, community services, or long-term care. The best way to find out what an insurance plan covers is to apply for programs and benefits as soon as possible after a brain injury.

You have the right to appeal if coverage is denied

If a service or benefit is denied, find out why. In some cases, updating the application or appealing the decision may lead to approval. Insurance plans often include multiple levels of appeal, such as reviews before or after services, reviews by experts, and expedited appeals. Understanding the process can improve your chances of success.

Understand your costs and how your insurance network works

Even with insurance, you will likely have out-of-pocket costs, which are the expenses you must pay yourself for care. These may include:

• Deductible: The amount you pay each year before your insurance starts to cover most services.
• Copayment (copay): A set fee you pay for a service, such as a doctor visit.
• Coinsurance: The percentage of the cost you pay after meeting your deductible (for example, you pay 20% and insurance pays 80%).

Most plans also have an out-of-pocket maximum, which is the most you will have to pay for covered services in a year. After you reach this limit, your insurance will usually pay 100% of covered costs.

Insurance plans also have a network, which is a group of doctors, hospitals, and providers that have agreed to work with your insurance company:

• In-network providers: These providers have agreed to lower rates with your insurance, so your costs are usually lower.
• Out-of-network providers: These providers do not have an agreement with your insurance, so care may cost more, or may not be covered at all.

The type of insurance plan you have affects how networks work:

• Health Maintenance Organizations (HMOs): Usually require you to stay in-network for care to be covered, except in emergencies.
• Preferred Provider Organizations (PPOs): Allow you to go out of network, but it will usually cost more and may require referrals or prior approval for some services.

Understanding these costs and rules can help you avoid unexpected bills and plan for your loved one’s care.

Employer-based insurance may offer coverage options

If you or your loved one has insurance through an employer, contact the Human Resources department or Employee Assistance Program to request a full copy of the policy. If they are unable to return to work, they may qualify for COBRA, which allows them to continue their health insurance for a limited time. While COBRA can be expensive, it may help maintain access to important care. Be sure to also ask about disability insurance or other employer benefits. Learn more about workers’ compensation and what to do if a brain injury happens at work.

Long-term care insurance is used to help cover ongoing support and services

Some people also have long-term care insurance, which can help cover ongoing care needs. These policies may pay for services at home, in assisted living, or in a nursing facility, and may also cover day programs, care coordination, or home modifications. Many plans have a waiting period before benefits begin and require that the person needs help with daily activities.

Compassionate answers. Real support. Every step of the way.

Contact the National Brain Injury Information Center at 1-800-444-6443 to speak to a specialist about:

• Help with care needs
• Legal and financial resources
• Services in your community