Insurance

• Does this care need to be pre-authorized or pre-approved?
• Do I need a referral from my primary care provider?
• What services, tests, or other costs will be covered?
• How many visits are covered and over what period of time (for example, 6-10 visits a year of acupuncture)?
• Is there a co-payment?
• Will the therapy be covered for any condition or only for certain conditions?
• Will any additional costs be covered, such as lab tests, dietary supplements, equipment, or supplies?
• Will I need to see a practitioner in your network? If so, can you provide me with a list of practitioners in my area?
• If I use a practitioner who is not part of your network, do you provide any coverage? Are there any additional out-of-pocket costs?
• Are there any dollar or calendar limits to my coverage?
• It will help you to keep organized records about all interactions with your insurance company. Keep copies of letters, bills, and claims. Make notes about calls, including the date, time, customer service representative’s name, and what you were told. If you are not satisfied with a representative’s explanations, ask to speak to someone else

4. What financial questions should I ask the practitioner?

Here are some questions to ask the practitioner or his or her office staff:

• Do you accept my health insurance?
• Do I file claim forms, or do you (the provider) take care of that?
• What is the cost for an initial appointment?
• How many treatments will I need?
• Can I receive treatment for a trial period to see if the therapy works for me before I commit to a full course?
• Will there be any additional costs?

It can also be useful to ask which insurance plans the practitioner accepts, in case you become interested in changing plans at some point (for example, through a change of employment).

If you do not have insurance coverage for treatment, and paying the full fee each time would be difficult for you, you might ask:

• Can your office arrange a payment plan so that my costs are spread out over a longer period of time?
• Do you offer a sliding-scale fee? (A sliding scale fee adjusts charges based on a patient’s income and ability to pay).

5. What about alternative medicine insurance coverage that may be offered through employers?

If alternative medicine coverage is offered, it is usually one of the following types: Higher deductibles. A deductible is a total dollar amount that the consumer must pay before the insurer begins making payments for treatments. Under this type of policy, alternative medicine coverage is offered, but the consumer pays a higher deductible.

Policy riders. A rider is an amendment to an insurance policy that may change coverage in some way (such as increasing or decreasing benefits). You may be able to purchase a rider that adds or expands coverage in the area of alternative medicine.

A contracted network of providers. Some insurers work with a group of alternative medicine providers who agree to offer services to group members at a rate lower than that offered to non members. You pay out-of-pocket for treatment, but at a discounted rate.

Employers negotiate with insurance companies for plan rates and services. This is done on a periodic basis (usually annually). You may wish to let your company’s benefits administrator know about any coverage preferences you have. If your company offers more than one plan, evaluate carefully what each one offers, so you can pick the plan that best meets your needs.

The Agency for Healthcare Research and Quality (AHRQ), a Federal agency, has helpful publications about choosing and using a health insurance plan.

6. My insurer has asked me for evidence, from scientific and medical literature, about the use of an alternative medicine treatment. Where do I find it?

They can help you find information from the scientific and medical literature on alternative medicine. They use databases of peer-reviewed scientific and medical journals, such as CAM on PubMed.

7. My insurance company has denied my claim for an alternative medicine treatment. Is there anything I can do?

There is nothing more frustrating than finding out a claim is denied. It has even happened to people after they have verified over the phone with an insurance company about a particular treatment.

As discussed earlier, make sure you know your policy-including what it is, and is not, supposed to cover. Check whether there has been an error in the coding or billing of your service (called a “coding error”), either by the practitioner’s office or by the insurance company; compare the codes on the practitioner’s bill with the codes on the document you received from the insurance company. If you think your insurer made a mistake processing your claim, you can request a review from the company.

Also, the insurance company should have an appeal procedure and provide a copy of it with your policy. It may be helpful to discuss with your practitioner whether she can do anything on your behalf, such as writing a letter. If you have taken these steps and the problem is not resolved, contact your state insurance commissioner’s office, which has consumer complaint procedures.

8. Are there laws to help me keep my health insurance if I lose or change jobs? Do these laws apply to alternative medicine treatments?

If you currently have an insurance plan that includes any alternative medicine coverage, the following laws may be of interest to you. The Health Insurance Portability and Accountability Act (HIPAA) of 1996 offers limited protection for many employed Americans. HIPAA protects health insurance coverage for workers and their families if the worker changes or loses his job. The law:

• Limits the ability of insurance companies to refuse coverage based on preexisting conditions.
• Prevents group health plans from denying or charging more for coverage because of past or present poor health.
• ssures renewal of coverage, regardless of any health conditions of people covered under the policy.
• Guarantees certain small-business employers, and certain people who lose job-related coverage, the right to buy health insurance.

They can provide you with the general information on the Federal HIPAA program. Note that individual states may have specific laws related to HIPAA requirements; if you need more information on HIPAA in your state, contact your state insurance commissioner’s office.

Another Federal law that may help you is the Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985. COBRA continuation coverage gives you the chance to buy and maintain your current group health coverage for a defined period of time if you are laid off or have your work hours reduced below the level for receiving benefits. The length of continuation coverage depends on the reason for your loss of group coverage. COBRA generally covers health plans of businesses with 20 or more employees, employee organizations, and state or local governments. You must meet certain application deadlines and other conditions, such as payment schedules, to maintain coverage under COBRA. COBRA can also help you avoid a gap in coverage if you change jobs and are not immediately eligible for coverage in your new company.

For more information about COBRA, contact your nearest office of the Pension and Welfare Benefits Administration of the Department of Labor.

9. What are tax-exempt accounts for medical expenses? How might they help me?

A flexible spending arrangement (FSA; sometimes called a Flexible Spending Account) is a benefit provided by some employers that offers a way to help pay for out-of-pocket medical expenses, while reducing the employee’s taxable income. With FSAs for health-related expenses, you choose an amount of pre-tax dollars to be set aside from your paycheck each pay period. This money is then available to reimburse certain health-related expenses that are not paid any other way, such as by insurance. You may need to supply documentation from a physician or other health care provider that the treatment is medically necessary. Note that the IRS does not allow the same expense(s) to be both reimbursed through an FSA and claimed as a tax deduction.

Another type of tax-exempt benefit for health-related expenses is a health savings account (HSA). Set up by Congress in December 2003, HSAs allow some individuals who participate in a high-deductible health plan to save money in a tax-free account. If you are eligible, you can use these savings to pay for your future medical expenses or those of your spouse or dependents. The IRS has publications with more information about FSAs and HSAs. The Department of the Treasury also has a direct link to information about HSAs on its web site.

10. Does the Federal Government have resources that might help me financially with my health-related expenses?

Currently, Federal health assistance programs are not set up to assist with alternative medicine expenses. They are intended to provide either direct support (direct payments) or indirect support (such as housing or child care credits, medical care at public clinics, or other social services) to people whom the Government determines to be in need. Examples include people who:

• Have a low income and limited resources
• Do not have other medical insurance
• Have a disability
• Are part of a population that has difficulty accessing medical care
• Are at least 65 years of age
• Have served in the military

There are Federal databases on the Internet that can introduce you to these programs. GovBenefits (www.govbenefits.gov) provides an overview and a self-test to help you identify whether any benefits are appropriate for your needs. FirstGov (www.firstgov.gov) has information on various health-related programs such as Medicare and Medicaid.

As part of its research, the National Center for Complementary and Alternative Medicine (NCCAM) does conduct clinical trials of some alternative medicine treatments. To find out more, go to www.nccam.nih.gov/clinicaltrials.

11. Are alternative medicine services deductible on my income tax?

As of 2002, the IRS allows a limited number of deductibles for CAM services and products.

12. Can you suggest any other resources?

If treatment (whether alternative medicine or conventional) for a disease or condition creates a financial crisis for you and your family, you may wish to try the following for more information:

• If you receive care at a hospital or clinic, that facility may have a social worker or patient advocate who can advise you.
• You may also find it helpful to contact nonprofit organizations that work on your disease or medical condition (try an Internet search or check directories at your local library).

Source: Consumer Financial Issues in Complementary and Alternative Medicine, National Center for Complementary and Alternative Medicine (NCCAM). http://nccam.nih.gov/health/financial/