Balance Billing: What You Need to Know

In order to avoid unexpected medical bills, it is important to know how your health plan Balance Billingworks and how a practice referred to “balance billing” can affect you. Most plans have a specific network of doctors and facilities that their members can use for their medical care. To be a part of a plan’s network, these doctors and facilities contract with the plan and agree to accept a specific rate for their services under the plan. These doctors and facilities are considered “in-network.” Doctors and facilities that don’t have a contracted relationship with an insurer are considered “out-of-network.”

The main difference between in-network and out-of-network healthcare providers is that in-network healthcare providers work with your insurance company to provide negotiated (discounted) rates, while out-of-network providers do not agree to discounted rates. For example:

You visit an in-network doctor and the total charge is $250. The doctor and your plan have negotiated a $75 discount. The plan then pays the doctor $140 (which they have agreed is the “allowed amount” for the doctor to receive). You then have to pay the remaining $35.

But, if you visit an out-of-network doctor and the total charge is $250 and there is no negotiated discount. The plan pays the doctor $140, but you’ll be responsible for the entire remainder, which is $110.

The latter part of the example regarding out-of-network doctors is an example of “balance billing.” Balance billing occurs when out-of-network doctors and facilities bill patients for the difference between a billed charge and a health plan’s allowed amount. However, this type of balance billing is typically not allowed when:

  • you have Medicare and you’re using a healthcare provider that accepts Medicare assignment;
  • you have Medicaid and your provider has an agreement with Medicaid; or
  • your doctor or facility has a contract with your health plan (in-network) and is billing you more than your plan’s contract allows.

Patients can also face balance billing when they receive care from a provider they did not know was out-of-network. For example:

You are going to have surgery at a hospital.  Both your surgeon and the hospital are in your plan’s network.  But during the surgery you need anesthesia so that you are not awake. The person who gives you the anesthesia, the anesthesiologist, whom you did not choose, is not in-network. A few weeks later you receive a large bill from the anesthesiologist, who was not covered by your plan. 

This is another example of balance billing, or “surprise billing.” Patients who think that they are being careful to only visit in-network providers are often surprised by these bills. Another example of when this often happens is when your doctor sends your blood to an out-of-network lab for testing. You can avoid this by asking your doctor to make sure they are using an in-network lab for your plan.

These situations can leave patients with huge medical bills that they are unable to pay, and can even lead to bankruptcy.

Some states have tried to protect patients from balance billing. For example, on July 1, a California law went into effect that says, if you have a non-emergency service and visit an in-network facility (like a hospital or a lab), you will only be responsible for your in-network share of the cost even if you’re seen by an out-of-network provider.

This is a giant step in terms of healthcare and patient care, as a recent Consumers Union survey found that nearly 1 in 4 Californians who visited a hospital or had surgery in the past two years were charged an out-of-network cost when they thought the provider was in-network.

In addition to knowing how to use your plan, you also need to make sure that you understand what type of plan you have. Because, the California law does not cover employer-sponsored plans that are self-insured. To find out of your plan in self-insured, you can call the number on your insurance card, or talk to your employer’s human resources representative.

New York and Florida also have comprehensive state laws to protect patients from balance billing. But there are a total of 21 states that have laws that deal with balance billing. To check if your state has a law protecting you from balance billing, visit Triage Cancer’s Chart of State Laws.

If you think you are being balance billed, there may be steps that you can take to deal with the bill.

People with Cancer are Stuck in the Disability Backlog

Tai Prohaska, MPH
Manager of Strategic Alliances, Allsup

Most people don’t know much about the Social Security Disability Insurance (SSDI) Disability-Backlogprogram until they have to stop working because of an illness or injury. Then, one of their first questions is, “Am I eligible?” They may qualify for monthly income (based on what they have paid into the system) and other benefits if they:

  • Are unable to work for at least 12 months or more, or their condition is terminal
  • Have paid FICA taxes for at least five of the last 10 years
  • Are over 21 and under full retirement age (65-67)

For more information about disability insurance options, read Triage Cancer’s Quick Guide to Disability Insurance.

While SSDI benefits can be useful, there are some barriers to getting access to these benefits:

  • It’s not easy to obtain benefits. Two-thirds of people who apply are denied and must go through an appeals process that can sometimes take years.
  • People are waiting an average 596 days for a disability hearing. Almost half of U.S. hearing offices now report waits of 600-plus days, including 14 offices whose times exceed 700 days. Click here for the average wait in your state.
  • After the hearing, people could wait an estimated 78 to 120 days to find out the judge’s decision.

The disability backlog was also an issue in 2009, when Allsup surveyed individuals going through the SSDI appeals process. Of those surveyed, 90% said they faced negative repercussions while waiting for their SSDI award. These included:

  • Stress on family – 63%
  • Worsening illness – 53%
  • Draining of retirement/savings – 35%
  • Lost health insurance – 24%
  • Missed mortgage payments – 14%
  • Foreclosure – 6%
  • Bankruptcy – 5%

Cancer is one of the top five categories of conditions that qualify someone for disability insurance benefits, according to the Social Security Administration (SSA). A 2013 study estimated that cancer accounted for 9% of all SSDI awards. Based on those numbers, we can only guess how many individuals with cancer are stuck in the SSDI backlog.

Banish the Backlog

One way individuals with cancer can improve their likelihood of avoiding the SSDI backlog is to get help at the very beginning of the process, starting with an eligibility assessment before they ever go to the SSA. Most people who apply through the SSA’s website for SSDI are denied. They don’t have enough work credits, do not submit adequate medical records, do not fill out SSA’s forms properly, or do not respond to the SSA’s requests for additional information. The process can be overwhelming and confusing.

Many websites offer tips on how to apply for disability. Allsup has a free online screening tool, empower by Allsup®, which also incorporates return-to-work information. Getting help with the initial application can mean the difference between getting benefits in a matter of months instead of years.

If you are stuck in the disability backlog and want to post your experiences and suggestions for tackling this problem, visit the Banish the Backlog Facebook page at www.facebook.com/banishthebacklog.

Early Withdrawal from Retirement Plans

Need Cash? Is early withdrawal from a retirement plan right for you?

Have you been financially impacted by a cancer diagnosis? Need access to money to Early-Withdrawlpay your medical bills or daily living expenses? Withdrawing money from your retirement plans may be an option for you.  However, it is important to understand the tax implications of doing that.

Fortunately, the IRS understands that you may need to dip into your retirement savings a little earlier than expected. And, unlike most of the tax code, this is pretty easy to understand.

Normally, if you withdraw money from a 401k or IRA plan before reaching age 59.5, you would be subject to an “early withdrawal tax” of 10%, above and beyond the normal income tax owed on the withdrawal. However, here are three exceptions to that rule, which can really make a difference:

  401K Plans IRA, SEP IRA, SIMPLE IRA, & SARSEP Plans
If the participant/IRA owner is totally and permanently disabled. No early withdrawal tax No early withdrawal tax
If your amount of unreimbursed medical expenses is greater than 10% of your Adjusted Gross Income. No early withdrawal tax No early withdrawal tax
If you are using your withdrawal to pay for health insurance premiums while unemployed. 10% early withdrawal tax applies No early withdrawal tax

There are close to 15 more exceptions to the Early Withdrawal Tax.  It is also important to know that with ROTH IRAs, you can always withdraw the money you’ve contributed (not the interest earned) tax free and penalty free.

When considering your financial situation as you face a cancer, remember to count every dollar. There could be money out there you thought you could not touch!

For more information on navigating finances after cancer, visit CancerFinances.org, read the financial topics on the Triage Cancer blog, or visit our other financial resources.

Uncertainty puts Marketplace Financial Assistance in Jeopardy

A recent study found that the average family in America spends 10.1% percent of the family’s income just on health insurance premiums and deductibles. So it’s no wonder Marketplace-Financial-Assistance-Jeopardythat many Americans need a little help purchasing health insurance coverage. The Patient Protection and Affordable Care Act (ACA) made financial assistance available for people who buy health insurance in the marketplaces, based on their income level. However, due to uncertainty in politics, as well as policy and legislative changes, that financial assistance may be in jeopardy.

There are two different types of financial assistance in the marketplaces:

  • Premium tax credits reduce the amount that people pay for their monthly premiums to have health insurance.
  • Cost-sharing subsidies, also known as cost-sharing reductions, help to lower deductibles, co-payments and co-insurance. The way that cost-sharing subsides work is that the insurance company reduces what they charge individuals and, in turn, the insurance companies are reimbursed by the federal government.

Since the beginning of the year, uncertainty has put these financial assistance options in jeopardy. The new presidential administration had suggested that they were going to eliminate the cost-sharing reductions and that they would repeal the ACA, which would eliminate the premium tax credits, as well.

While health insurance companies are accustomed to dealing with uncertainty, like not knowing how many people will get sick during a given year, it is unusual for politics to create such uncertainly in the health insurance market.

Specifically, the uncertainty that will have the greatest impact is the fact that there has not be a clear decision from the President or Congress on if they are going to continue funding the cost-sharing reduction payments to insurance companies, and whether the individual mandate will be strictly enforced. The individual mandate was designed to insure that individuals do not wait to purchase insurance once they are sick. The IRS has already indicated that they will not strictly enforce the mandate moving forward.

Oliver Wyman, an actuarial consultant, states that these sort of ambiguities are new to actuaries who are in charge of setting the rates, and actuaries are predicting that 2018 insurance premiums are expected to increase between 28 and 40%.

Ultimately, the uncertainty around cost-sharing reduction payments, and the lack of enforcement of the individual mandate is projected to be responsible for the bulk of premium increases for 2018 and has already led some insurers to pull out of the marketplaces in some states, to avoid having to deal with the uncertainty.

This uncertainly, along with the current proposals for health care reform being discussed in the U.S. Senate, have the potentially to significantly impact the cancer community.

Stay tuned to our blog for the latest updates on proposed changes to our health care system.

Senate Health Care Proposal – Take 2 

Yesterday, the U.S. Senate released its revised proposal to overhaul health insurance in Senate Health Care ProposalAmerica.  Unfortunately, this new version of the Better Care Reconciliation Act (BCRA-2) would still cause significant harm to the cancer community.

For clarity, here we will focus just on the changes to the Republican proposal that we will refer to as BCRA-2.  Read more about the first version of BCRA.

The major provisions to take note of in this new version include:

  1. Cutting the Medicaid program so significantly that 15 million fewer people would have coverage, according to the Congressional Budget Office.
  2. Allowing insurers to sell plans with bare-bones coverage (“junk insurance”), as long as they also sell at least one policy that meets the ACA’s requirements. The concern is that by allowing individuals to purchase this less adequate, but cheaper coverage, healthier people would gravitate towards these plans, and people with pre-existing conditions would stay in marketplace plans, which would result in an unbalanced risk pool, and higher premiums for people buying marketplace plans. In addition, it would lead to higher medical debt for individuals buying junk insurance if they need medical care and find out that they only have bare-bones coverage. This was exactly a problem that the ACA was trying to address by creating minimum standards of coverage for plans being sold.
  3. Allocating $45 billion to deal with opioid abuse, a clear concession to two Republican Senators’ request.
  4. Adding $70 billion to help states stabilize their insurance marketplace.
  5. Keeping an ACA provision that places a 3.8% net tax on investment income and a 0.9% payroll tax on individuals making more than $200,000 annually.

While the BCRA-2 does contain some minimal improvements from the Senate’s original version, it ads changes that would be more harmful to the cancer community and others with pre-existing medical conditions. And, the overall impact of this proposal is still detrimental to most Americans.

Next Steps

In order for the bill to pass the Senate, the Republican Leadership need 51 votes in support.  There are 52 Republican Senators and 48 Democratic and Independent Senators. If there is a 50-50 tie, the tie can be broken by a vote from the Vice President of the United States, who is a Republican.

Moderate Senator Susan Collins (R-ME), has announced she wouldn’t support a procedural motion to allow debate on the bill. Conservative Senator Rand Paul (R-KY) also is unlikely to support the bill due to the fact that it doesn’t completely repeal the ACA. Therefore, Republicans can only afford to lose one more vote, if they want to pass the BCRA-2. Three other moderate Republicans have expressed serious concerns about this legislation: Dean Heller (R-NV), Shelley Moore Capito (R-WV), and Rob Portman (R-OH).  Senate Majority Leader Mitch McConnell has indicated that he wants a vote on BCRA as early as next week.

Do You Need Health Insurance Now?

If you do not have health insurance coverage, you can apply for Medicaid at any time or purchase a policy through the State Health Insurance Marketplaces if you qualify for a special enrollment period.

  • For more information about how to choose a health insurance policy (including making choices between employer-sponsored options), watch our recorded webinar.
  • If you aren’t sure what your health insurance options are or want to understand more about health insurance, visit CancerFinances.org.

 What You Can Do

  • Contact your U.S. Senators and share your health care concerns, by calling (844) 257-6227. Even if you’ve called before, please call again. Even if you know how your Senators will vote, please call to share your thoughts.
  • To find your elected officials or learn more about becoming an advocate, visit our Advocacy resource page. You can also find the Facebook and Twitter handles for the current members of Congress here.

 Stay tuned to our Blog and sign up for our newsletter, as we will continue to provide updates as more information becomes available, about this issue that affects all of us.

Is a Reverse Mortgage Right for You?

by Kristi Sullivan, CFP

Chances are high that when I mention the idea of a reverse mortgage to clients, I’ll be Reverse Mortgagemet with a very sour expression. I think this is because of the impression that these instruments are expensive and that you give up ownership of your home to use them.

Now I am no expert in these products, but for clients who have most of their net worth tied up in their homes, finding a way to use that equity to pay bills is a must.

Reverse Mortgage Basics

Here are some reverse mortgage basics:

  • Reverse mortgages are also known as home equity conversion mortgages (HECM) and are administered by the FHA.
  • You enter an arrangement with the lender to take money out of your home based on the amount of equity you have and your age.
  • You don’t have to have earned income to qualify.
  • You keep the ownership of your house until the last occupant dies or moves out.
  • You can receive the income from home equity in a variety of ways: For a specific time period, as a credit line to use as needed, or for your lifetime or the time that you or your spouse occupy the home.
  • When you pass away or move from the home, whatever equity is left after the debt and fees are paid will pass back to you (if living) or to your estate. (For related reading, see: How Does a Reverse Mortgage Work?)

An HECM is different than a home equity loan or line of credit. With a traditional home equity loan, you have to pay back the principal and interest over time. With a reverse mortgage, your house actually pays you.

Benefits of a Reverse Mortgage

Brainiacs who are way smarter than me have been modeling the use of a reverse mortgage in retirement planning. The numbers show that using home equity for income, especially when retirement investments are down, can lengthen the time your nest egg will last. Wade Pfau has been doing research on the use of reverse mortgages in retirement income plans and says there are two big benefits:

  1. Using a reverse mortgage early in retirement can reduce the stress of market volatility on the invested portfolio by allowing people to live off of their home equity rather than selling investments when values in their accounts are down.
  2. The second benefit is that opening a reverse mortgage now (especially with current low interest rates) can allow for the principal that you can borrow against to grow for a longer time.

Not everyone can get a reverse mortgage. You must be at least 62 years old, live in a single-family or two-to-four-unit home, and there is a limit to how much mortgage debt can be against the home at the time you apply for the HECM. (For related reading, see: The Reverse Mortgage: A Retirement Tool.)

This is not for everyone. Some downsides are:

  • The closing costs and fees on reverse mortgages are more expensive than conventional loans.
  • You may be tempted to spend your home equity on dumb stuff instead of using it prudently.
  • You still must have enough income or savings to maintain the home and pay property taxes and insurance.
  • There are people out there selling reverse mortgages who may not have your best interest at heart. Investigate and get several quotes before deciding on who to use for a reverse mortgage. (For related reading, see: Beware of These Reverse Mortgage Scams.)

If you are feeling your retirement income is too tight and you meet the eligibility requirements, using your home equity through a home equity conversion mortgage may be worth investigating.

Check out more from Wade Pfau in this Forbes article. For more information, you can also call National Council on Aging at (800) 510-0301.

This post originally appeared at Investopedia on March 3, 2017. 

Living Paycheck to Paycheck and then . . . Cancer!

Paycheck to PaycheckAt the beginning of 2016, headlines all over the country read something like “63% Of Americans Don’t Have Enough Savings to Cover A $500 Emergency.”  This alarming statistic was according to a 2015 study by Bankrate.com.  What it really meant is that nearly two-thirds of us are living paycheck to paycheck.  What does a $500 emergency look like– your car needs new breaks, your dog has to go to the vet, or your refrigerator breaks down. These are not uncommon expenses, and they shouldn’t be unexpected expenses.  Nevertheless, 63% of us are not ready to face these everyday emergencies.

What happens when someone in that 63% of Americans is diagnosed with cancer? It can lead to a financial catastrophe. Thanks to the Affordable Care Act (ACA), more Americans have health insurance than ever. But for many people, including those with health insurance coverage through their employers, that insurance doesn’t kick in until they meet their high deductible. If they don’t have $500 in savings, they certainly don’t have the money for their deductible, which often ranges from $1,000 – $10,000. For those without health insurance, they have to pay the entire cost of their cancer treatment. For those with insurance, patients often report being left with out-of-pocket costs ranging from $25,000 to $40,000, beyond what their insurance covered.

Cancer is expensive.  Patients face a myriad of expensive diagnostic tests and therapies including CT scans, MRIs, surgery, chemotherapy and/or radiation, hospital stays, anesthesiologist fees, on-going multiple doctor visits, lab testing, and more. According to the Kaiser Family Foundation, the cost of chemotherapy is going up 10% per year!  And all of this doesn’t take into account lost wages, travel expenses, child care expenses, and other unexpected expenses that may come along with a cancer diagnosis.

If you find yourself or a loved one in this situation, there is help.  Triage Cancer has many financial tools and resources available to you:

Talk with your health care team, as they may know of local resources, as well. The key is not to assume that you don’t qualify. If you don’t ask, you will never know. Remember, you aren’t the only one possibly living paycheck to paycheck.

Unexpected Costs of a Funeral

Too many people are caught off guard by the cost of a funeral. In general, funeral costs Unexpected Costs of a Funeral are not something you think about until you are at a very vulnerable point in your life. You are grieving the loss of a loved one and at the same time, being forced to make very expensive funeral decisions. Our hope is to provide you with a valuable perspective of the hard costs involved in a funeral and provide resources to help you start to plan for some of those expenses.

There are three main cost categories in funeral planning: costs related to the funeral home, the cemetery, and the grave marker. These costs can easily range from $3,000 to $15,000.  We know that these costs can vary greatly depending on where you live and what you choose, but here is a list of the most common expenses:

Funeral Home

  • Funeral director’s basic services fee
  • Embalming and body preparation
  • Casket
  • Funeral ceremony and viewing
  • Miscellaneous (e.g., hearse, death certificates, obituary, memorial services, flowers, music, prayer cards, motorcycle officers to escort a funeral procession between a memorial and burial site, and other custom features)

Cemetery

  • Grave site (plot)
  • Open/Close Fee (digging and placing the casket in the grave)
  • Fee to place the grave marker (also called a head stone)

Note: most cemeteries have rules about the type of headstones allowed, including the size and features.

Grave Marker

  • Headstone

Note: the price of a headstone is generally calculated by weight, so the larger the headstone, the more expense it will be. If you want custom features such as an engraved photo or image, that will cost more.  If you are not purchasing the headstone from a cemetery, but from another retailer, you may also have to pay to ship the headstone.

The good news is that if you are prepared for these costs, you can reduce them and find strategic ways to pay for them. For instance, you can compare prices of funeral homes. Funeral homes are businesses and just as you would compare prices on anything else, you can compare funeral home costs. Also, though the funeral home may not have it on display, they must offer a simple pine casket. You can even buy your casket at Costco. A funeral home cannot require you to buy a casket from them. In addition, no state requires embalming if certain time constraints are met.

Depending on your preferences, you could also consider cremation. By 2025, it is expected that 56% of people will choose cremation. Cremation can be less expensive, averaging around $3,200 plus the cost of a $20 urn that you can buy online.

Some funeral homes and cemeteries will not accept credit cards or payment plans, but require payment in cash and up front. Some funeral homes and cemeteries will allow you to set up a payment plan, if you pre-plan a funeral. You can also consider purchasing funeral or “final expense” insurance, to cover the cost of expenses.

Don’t let funeral costs catch you off guard.  Thinking through these options and your preferences can help you be prepared and avoid overpaying for a funeral.

For information about pre-planning:

http://www.nfda.org/consumer-resources/planning-a-funeral

https://www.funerals.org/consumers/

For more general information about estate planning.

2017 Raise for Social Security & SSI

Triage Cancer Blog SSA Disability Insurance

The Social Security Administration (SSA) recently announced that the cost of living adjustment (COLA) for 2017 will be a 0.3 percent increase for Social Security and Supplemental Security Income (SSI) benefits.

That means that the SSI federal benefit rate in 2017 will increase by $2 to $735 per month for an individual, and by $3 to $1,103 per month for an eligible couple.

The estimated average monthly Social Security benefit payment will increase by $5 to $1,360 for retired workers, and by $4 to $1,300 for surviving spouses.

This marks the first COLA in two years, as there was no adjustment in 2016.

We will have to wait until next month to learn what the Medicare premiums for 2017 will be.

For more information on the other benefit changes for 2017, visit https://www.ssa.gov/news/press/factsheets/colafacts2017.pdf

Prescription Drug Coverage: New Recommendations from the National Association of Insurance Commissioners

As someone dealing with cancer, you are probably no stranger to the exorbitant costs of triage-cancer-blog-rx-drugs-naicprescription drugs.  In fact, the cost of all drugs, not just cancer drugs, has received quite a bit of news coverage lately. Everyone admits there is a problem, but very few have identified any solutions.  Now, the National Association of Insurance Commissioners (NAIC) has done just that.  At the NAIC’s summer meeting in August, a report was issued with a list of recommendations for state and federal policymakers to improve access to affordable prescription drugs.

Key Recommendations:

  • Limit consumer out-of-pocket costs, by, for instance, prohibiting co-insurance for prescription drugs
  • Prohibit insurance companies from changing their formulary mid-year, if it negatively affects enrollee access to drugs
  • Limit the number of drug tiers that insurers can use
  • Require formularies to be updated weekly and include information about drug tiering, the actual dollar amount of any cost-sharing, any utilization management or network restrictions, and the process to request a drug exception, among other information
  • Adopt standardized plans with meaningful cost-sharing limits to lessen the effects when an insurance company uses drug tiers
  • Collect standardized, plan-level data to enable the development of consumer tools and apps
  • Solicit feedback from external stakeholders—such as advocates, other state agencies, ombudsmen, and independent medical experts—to inform the formulary review process.

Frustratingly, these recommendations won’t translate into meaningful change for quite some time.  Still, without consumer advocates starting the conversation about reform, change would never happen.