Webcast
KMCO Archives
How
to Select a Health Plan for Your Family & Child with Special
Health Needs
(Originally webcast February 23, 2000, 1:30 pm
CST)
Good
morning everyone. We're really happy that you're with us. This
is Faye Eldar from the University of Illinois School of Public
Health. I'm the Family Coordinator for the Quality Community
Managed
Care project,
and this morning we are doing a program about How to Select
a Health Care Plan for your Family and Child Who Has Special
Health Care Needs."
Our speakers this morning are two people
who are very knowledgeable in this field and we're really happy
that they have agreed to share their expertise with us.
The
first speaker is Robin Speaks. Robin is the team leader for
Admitting And Business Associates And Patient Financial Services
at Children's Memorial Medical Center in Chicago, Illinois.
Robin has been with the hospital for over 20 years and she oversees
a staff of 20 staff members who are involved with the patient
financial services and benefits. Children's Memorial is the
largest children's hospital in the state of Illinois. She is
a very knowledgeable person. I met her first when my child was
a patient at the hospital and we have continued to work together.
The
second speaker is Kathy McCarthy. Kathy and her family live
in Crest Hill which is a southwest suburb of Chicago. She has
a 14-year-old son and a 7-year-old son. Her 7-year-old son has
special health care needs. He has a condition called spinal
muscular atrophy. Kathy and her husband recently selected a
new health plan for their family and this is the reason that
we have invited her to be on our program today.
We
are aware that very often individuals and families don't have
a choice of health plans and they only have one health plan
available to them, but frequently, people get a choice of health
plans typically at an open enrollment period at their job or
when they are changing their employment. What all families need
to do, but particularly families of children with special health
care needs is make a decision about a health plan that will
meet the child's special needs as well as serving the health
care needs for the entire family.
Q.
Robin, can you tell us how people find out about managed care
plans that they could choose from?
A.
Well, typically a person can find out about managed care through
their employer. A lot of information is provided. A lot of material
is provided through the employer. For example, booklets, handouts,
leaflets and one of the important things that one must do is
call and ask questions about that particular managed care program.
Ask questions and keep asking questions until you're satisfied
with answers. Policyholders still don't understand the process
and especially if you have a special needs child. So it's very
important to ask questions through your benefits person at your
job or ask other people who may be in those HMO plans or PPO
plans, which is the preferred provider organizations. Keep asking
questions until you are satisfied with answers.
Q.
Kathy, can you tell us how you and your husband got informationthat
you used in making your decision about changing your health
plan?
A.
As Robin had said, you can get it through your work or through
human resources during open enrollment. With my husband's employer,
they had a choice between the HMO or the PPO. So he looked into
the PPO because from what we understood, PPO's have where you
can choose the physicians that you want to go to but also because
Mark has SMA, we wanted to choose physicians that knew a little
bit about that and what they could offer us as far as helping
Mark.
Q.
Kathy, could you tell us what is SMA?
A.
Spinal muscular atrophy. It is a genetic disease that affects
muscles and spine, which is like the name, spinal muscular.
Well, they are lacking this SMN gene which makes your muscles
work so therefore, the muscles become weakened and because they
are not being activated, they become atrophied.
Q.
Okay, thank you for explaining that to us. Robin, what are some
examples of questions that people should ask when they are considering
a new health plan?
A.
Well one of the things you should ask, especially when children
are involved, who are your pediatric specialists and what hospitals
are they located in? What are their specialties? Are they board
certified? How long have they been working in this field? How
many patients do they manage? Besides the normal questions that
you go through, find out what other programs are available?
Is there durable medical equipment available or home health
care? Can you provide speech, physical or occupational therapy
or things that would be of particular interest to your child
if that child has special needs?
Q.
I have a couple things I would like to ask about that, Robin.
Could you explain what it means to be board certified and why
it's important for families to know about that?
A.
Board certified means that this particular physician is an expert
in that particular field. He or she has gone through the fellowship,
has gone through their residency and internship and has a number
of years in the field that they are working in. To be board
certified means that they have met all the criteria of the medical
organizations and they are an expert in that field.
Q.
So this would help somebody find a doctor who had the most expertise.
A.
The most expertise, correct.
Q.
Okay thanks. What kinds of questions should people be asking
about the costs involved with the different health plans?
A.
That's a very good question because many of the products
of the insurance plans have different costs involved. They have
a co-payment or a deductible. Let's say for instance you are
going to use the doctor's office and there may be a co-pay of
$10. That is synonymous with whatever plan the insured has chosen
with the particular insurance such as $50 for an emergency room
visit or their may be no cost at all, depending on the plan
or product of the insurance company. So it is very important
to ask what the cost is to me or the family if I use this PCP,
which is primary care provider or specialty, or an emergency
room. So you have to keep all of those questions in mind. How
much is it going to cost me besides my regular premium or payroll
deduction for my premium.
A.
But in addition to paying a premium for the cost of your
health care in which your employer also shares a part of that
cost, you in addition will have to make a co-payor a deductible.
So if you are paying $38 for a single plan or maybe $100 for
a family or group plan, in addition to that for each visit to
the doctor's office or each visit to the emergency room, there
is a cost involved and you need to ask what is the additional
cost to me?
Q.
Would you say between health plans, each one has different costs
and different charges?
A.
The most that I've seen with some of the HMO's or the points
of service or the PPO's is a $10 co-pay for an office visit
and anywhere from $25 to $50 for an emergency room visit.
Q.
So what you're saying is that people have to be prepared in
addition to the monthly charge that may be taken out of their
paycheck, they will have to pay an additional sum, depending
on how many medical services they need.
A.
Correct.
Q.
Kathy, can you tell us about your family when you were looking
at health plans? What questions did you ask and what decisions
did you make about costs to you?
A.
What we did was we talked with the people in the human resources
department about how much the plan itself would cost us
monthly. The plan we have now does cost considerably more, but
the benefit of that is that we can keep the same physicians
and Mark would not have to change doctors and then we would
have to go through the whole thing of reintroducing Mark to
a new physician and have the physician look over Mark's history.
This way we can keep the physician that we have. So that was
really important to us. Mark is 7 so to have him still feel
comfortable with the same doctor and not have to change over
was important. Also for myself and for my husband, for just
the regular office visits, how much would that cost as to what
we were paying before? If we did need to change doctors, where
are they located and what hospitals they would admit to or did
they have physician privileges at the hospitals they go to.
How far did we need to travel if it was out of our town? All
those things I think are really important. The thing is like
Robin had said, you really have to ask because a lot of times
the insurance company will give you the basics because that
may be all they are required to do. But I think if you want
to know what you need, you need to ask because it is your child
and you have that right. You're the speaker for your child.
Your child is the person who's getting the care, but you're
the one that's got to do all the leg work so to speak. All those
were very important factors.
Q.
Who did you ask? did you ask somebody in the work place or somebody
who was an employee of the insurance company or someone else?
A.
I had asked for a booklet through my human resources. From that
booklet, I looked to see who the providers were, who the physicians
were. At that point, I had called the doctors' offices and I
asked them have you dealt with a child who has SMA? How many
children do you see? Most of the time I try to get a pediatric
neurologist as opposed to a neurologist. I wanted somebody specific
in that field who would deal with children. I called the insurance
company and asked: Is this doctor covered under your plan? A
lot of times you have to do that. You have to call your insurance
company to find out if your doctors are covered. Even though
you think they are, when you get the statement back that says
oh no your doctor is not in this plan or in this network. It's
time consuming. It takes a lot of leg work. But this way, you
are more prepared and you basically know everything rather than
going into something and not knowing. You do have the right
to do that. You can call insurance companies and ask them. The
insurance company we have has been more than helpful. They will
give you that information. They'll say well this doctor isn't
and sometimes they'll say this doctor is. If they say no that
doctor is not, then it's up to you to ask well then who is?
Sometimes they can give you a list of who is. Then you just
have to call these doctors.
Q.
Kathy, I have a couple more questions. The first one is why
did you make a decision to change your health plan and how much
time did you have from when you made this decision until you
had to tell your employer which health plan you wanted?
A.
The reason why is I was thinking about changing jobs. We weren’t
sure that if I were to get a different job, what insurance would
they have or would they have any at all? We knew that my husband's
place of employment did carry insurance. So what we have at
the place where I work is the open enrollment that Robin had
spoken of where at different times of the year you can enroll.
Also the same for my husband where at different times of the
year you can enroll. If there is a change in the family situation
such as if you get married or divorced or if there is a death
or birth in the family, those are exceptions where
you can change from having to go through the open enrollment.
Typically, you have to wait until open enrollment. for me we
had a month's time. So between the time I wanted to drop my
insurance and add my husband's, we had a month. Within that
month's time, we were covered, but instead of just going ahead
and dropping it, I went ahead and contacted the insurance companies
and doctors' offices and the places of employment, both mine
and my husband's. I just went ahead and did everything. I asked
questions and found out who was covered and who was not covered,
how much the deductible was and how much out-of-pocket would
be, how much the office visit would be and if they had a prescription
plan. A lot of times that's important too if they have a prescription
card. Otherwise, medications can cost a whole lot. I had a month
to be able to say okay, I do want to change or I don't want
to change. Luckily, with our places of employment, they pretty
much carried a lot of the same physicians.
Q.
It sounds like you must have spent hours and hours on the telephone.
A.
Yes Like I said, it's time consuming. But I felt it was worth
it in the end because knowing that I was prepared ahead of time,
I knew where my son was going to go. I knew the doctors already.
It made me feel more at ease to know what to expect instead
of just going in cold and not knowing anything. This way you
can prepare yourself. This way, I knew what to expect and how
much it was going to cost me. Another thing I needed to do in
the event of let's say they're not going to pay for this. I
needed to find out what other services I could get that may
help to offset the cost?
Q.
So this is really a complex process when you have a child with
special needs and you're planning to change your health plan
and start in a new health plan. Could you tell us a little bit
about the materials that you share with the families?
A.
Sure. We have booklets and brochures about knowing the process
of MCO's which is Managed Care Organizations, whether they are
HMO's or PPO's or EPO's or POS, Points of Service and Fee for
Service, those types of things. It's very educational for those
consumers who are very interested and who really care and are
pro-active and an advocate for their child. They will read this
information and there are telephone numbers listed with the
different insurance companies. We're not advocating any particular
insurance company. You can ask questions and get answers to
your questions. We also have telephone numbers available, and
I don't have any in the office available with me right now,
of the Illinois Insurance Commission if you have questions or
concerns about different health plans.
Q.
Robin, what is the insurance commission? Is that a private agency
or is that part of the government?
A.
It's part of the government.
Q.
What do they do?
A.
They will investigate any kind of concern that you have. If
you think you are being treated unfairly with your insurance
company or if you are not getting the services that you need
or you are not getting the proper paperwork done that you need,
you can go to the insurance commission and they will investigate
that particular insurance company or that particular medical
group or a particular doctor for you and they will report back
to you their findings.
Q.
Okay I know that the brochures you're talking about and information
about the insurance commission and other resources will be on
the web site under resources and anybody who is listening to
this broadcast can click on to the resources.
Q.
I would like to talk now about families and professionals talking
to doctors who are currently treating the child when you are
making a decision about changing your health plan. Is this something
families should do and do doctors have discussions about different
health plans? Maybe each of you can fill me in a little bit
about this from your perspectives.
A.
Kathy, do you want to go first?
A.
Sure. Most of the time I didn't speak to some of the doctors
about switching over. The only thing I did when I thought about
moving over, I had asked the doctor if they were in this plan.
They pretty much said yes. A lot of times the doctors may say
each insurance plan is different. Check with your insurance
company. If
I needed other services that my insurance didn't cover, well
there is this one we go through called DSCC, Department of Specialized
Care for Children. They will help to offset the cost. Now I
did not know about this particular organization, but the doctor
said well here are some that we have referred other families
to. So from my experience, doctors have been helpful in that
respect. They will also help you in that respect like if you
can't pay for this, they can help you with something that is
called a sliding scale such as pay what you can or they will
say these are other places that will help you pay for that that
your child can keep going to. I have not met a physician yet
that said oh if you can't pay, I can't see your child. I have
never encountered that at this point.
Q.
Well this is really important information. This is something
else we will be putting up on the web site in our resource list.
Every state in the United States has a Title 5 children with
special health care needs program. In Illinois, it is called
the Division Of Specialized Care For Children and we will have
the contact information for this program so families can get
connected to what is available in their state. Robin, can you
tell us a little bit from the hospital perspective about discussions
with physicians related to choosing a health plan?
A.
Well I was agreeing with Kathy there that doctors are becoming
a
little bit more savvy about health care insurance plans and
different provider groups whereas 2 or 3 years ago, they didn't
really know. I've never heard except in some cases that a physician
will not treat a child because you don't have a particular insurance
or you're out of network. But very often, the physicians will
sit down with the parents or the insured policyholder and will
discuss their insurance plans and what their particular rules
or policies are with the parents. Most of the time it is agreeable
concerning information being passed between the parents and
physician. But many times, it is the parents or policyholder
that has to do the leg work or the telephone work to get the
most information for the questions they are asking. The physicians
really don't know.
Q.
There is one other thing I wanted to remind everybody that
often comes up in discussions with families is that there are
many many different insurance companies out there but each employer
makes their own contract with the insurance company so you and
your neighbor might have insurance from the same company, but
you have different employers and that means that the benefits
in your health plans will be different, depending upon what
your employer signed up for with the insurance company.
A.
That's correct.
Q.
Now I know many children who have special health care needs
need things such as medication, equipment, supplies, different
kinds of therapies and treatments, ongoing medical tests and
nursing care. I would like to talk now about how you find out
if these things are covered and how they are covered and how
you arrange them to meet the child and family's needs. Kathy,
could you tell us about this from your perspective?
A.
Sure. A lot of times too, it's my experience that it was just
like on an as-needed basis as far as Mark. We did not know that
Mark was going to need a wheelchair, although we did see maybe
years down the road. So we did look at our insurance policy
for a clause that is called Durable Medical Equipment. They
did provide so much money for that. At one point, one of the
insurances that I had felt that this was something that was
not needed at the time, so what we had to do is we had to appeal
it. We got a physician's letter as to why he needed it, what
it was used for and that it's not just something extra, but
that it is something that's of a medical necessity. Sometimes
you do have to do that. Now this is something that Mark did
need and sometimes the insurance company at the time may say
no this is something that is not needed or we don't see why
it's needed. So we might need a little more information to go
on. So that's where you can work with your physician on this
and say hey, this is what's happening. Then you get the letter
from the physician and the physician can write down their recommendations,
why they are recommending this, what it's needed for, etc. We
had to do that at one point and we sent a letter in and the
insurance company will review it and then, like I said, fortunately,
they did come back and say okay fine. But at first, if they
deny and it's up to you like Robin said, you got to keep going.
Just keep going back and say what other information do I need?
Work with your physician on this and say hey, the insurance
company is saying this and what can you do to help out? A lot
of times the physicians will help out because that's what they're
there for. They are there to help you. I've had no problems
with my physicians writing what they call letters of necessity
and then
again it's sent to the insurance company. I keep copies of
everything in case for some reason it may get lost in the mail
or something comes up. But I keep copies of everything. The
insurance company will review it and then they send a letter
either back to you for an explanation of benefits or maybe to
the doctor.
Q.
Robin, is there anything you'd like to add on this topic?
A.
I think Kathy said it all.
Q.
I would like to talk about needs that families may have from
a health plan that are not strictly medical, but they are more
like things that we call enabling services or accessibility
needs. For example, finding out when you are looking at health
plans if English is not the family's first language, how do
you find out if there are providers who do speak your language
or find out if the office is accessible to a child who uses
a wheelchair or other mobility equipment, if they have a library
of health care information or any seminars. Is there help with
transportation? Do they have interpreters? Do they have service
coordination? Do they have lectures about special health care
needs that families can go to. How do people find out about
these things?
A.
With the information that is provided by the insurance plan.
Language could be a little bit difficult. I think you need to
start out with someone who can speak English. Then find out
the information from the physician's offices. Keep asking the
questions or can they bring someone in who can interpret for
them
into their language? Do they have accessibility to the AT&T
language line with access codes? Keep asking those questions.
As far as transportation, some insurance companies will provide
or pay for transportation, but again it needs prior authorization
and how do you do that? You do that by having that relationship
with your primary care physician and a letter of necessity and
sending that to the medical director. A decision can be made
with that. The key is asking questions and following up.
Q.
Do you do this over the phone or on the internet or are there
other ways to do this?
A.
It can be done on the phone. It can be done in person. It can
be done on the Internet. Any type or line of communication can
be done.
Q.
Do all insurance companies have case managers or service coordinators?
A.
Most of them do to coordinate the care. They have a continuum
of care for chronic illnesses, so you stick with one case manager
and perhaps one primary care physician so those two people will
know everything about your medical care, about your history,
what your needs are, and they can coordinate different things
for you.
Q.
Can everybody get a case manager or do only some people get
them?
A.
Those who have chronic illnesses are assigned case managers
and yes, they will be with you from beginning to end. Now you
may have difficulty sometimes with your case manager, but the
more you talk and the more you share information, the more your
primary care physician is involved with the case management
of the child or patient, then the better services you will get.
Q.
Kathy, can you tell us about your experiences in working with
a case manager through an insurance plan?
A.
One of Mark's case managers has been very helpful. She is his
primary case manager so as Robin said, it's great because they
have the history of the child. You don't have to explain to
a new person every time what is going on. They keep everything
on file so that they know what's been had, what isn't, what
needs to be done, etc. They are pretty knowledgeable and they
also can help you in different ways. They may even ask you questions
that you're not sure to ask. For instance, we had to size Mark
for his wheelchair. As he grows, the wheelchair will essentially
grow with him. So, she asked the question is this going to be
a whole new chair or is it just going to be parts? I thought
that that was a good question because I didn't think about that.
So, I had to go back to the person who makes the chair and ask
them that because a new chair may cost more than just the parts.
So, that's a good question in that respect because they are
also looking out for your benefit as far as how much it's going
to cost you as well as for themselves. They may ask questions
like that which could help you out in the long run or something
that you may not think of. Sometimes you can come across difficulties
where they may say something like I don't know if we can really
provide that. That's when you have to speak up and say that
and say well that's what I'm being told from the doctor. Let
me go back to the physician and ask him and I will get back
to you. If you keep it amicable and try not to attack somebody,
they will be more receptive just like we would be more receptive
if somebody was helping us rather than attacking us. The case
manager can say no way, we're not going to pay for that. That
could just put a wall up. Try to keep the lines of communication
open. Remember that they are there for you, but they are there
for the company and they can only do so much. They are people
too. Just try to work together on this. Ultimately, this is
for the benefit of the child.
Q.
Well, that is really good advice, Kathy. You have now switched
health plans. Do you have a new case manager in the new plan?
A.
Actually, the case manager that Mark is assigned to is through
DSCC. Now the insurance company itself, it's like a same company
but it's a different branch. So all of Mark's records went over
to this new branch. So even though I work with a different person
on the phone who is in the claim department, they have everything
of Mark's there. They have his history because what I would
ask them is do you know about my son? And then they say let
me bring up his information so they have it right there. So,
that's what I ask, do you know about my son? Are you familiar
with his case? If they aren't, then I know what I need to do
to inform them about my son.
Q.
So it sounds like you have this really well thought and planned
out.
A.
Well at first I didn't. At first it was very overwhelming.
Q.
Robin, we've been hearing a lot lately when people talk
about quality assurance and health plans and health care report
cards and things like that
which we see in the paper, can you tell us a little bit about
what is quality assurance and what it has to do with health
care and making decisions about health plans?
A.
Well simply put and I can tell you about one organization called
the National Committee For Quality Assurance. That is a committee
that gives accreditation which is granted to managed care plans
that deliver sound care and sound service. They have systems
for consumer protection and quality improvement that meets their
rigorous requirements. So any one of these MCO's Managed Care
Organizations, if they are accredited by the NCQA, you are guaranteed
to get the best of quality care and sound medical services by
a medical provider.
Q.
How would people find out about this?
A.
You can call the association and again I'm sorry I don't have
that phone number right now, but I will have it for you later,
to find out if that insurance or that product of the insurance
is accredited by the NCQA. You can look it up on the Internet
as well. Many times the insurance companies or plans or products
will volunteer that information.
Q.
Do you feel it would be important for families to find out about
this?
A.
Yes and I would encourage anyone who has either signed on or
is currently on an MCO to find out whether your insurance or
the product of the insurance is accredited by any one of the
organizations, but particularly the NCQA.
Q.
I know you mentioned when I spoke to you earlier before the
show
that you are involved with a parent organization related to
your son's disability. Were you able to get any information
from them about selecting insurance plans?
A.
To be honest with you, I didn't ask them, but they do provide
that service. They do send out a newsletter and they do have
different services. You can always call them. they have an 800
number and you can call and they have a listing of different
physicians in the area who may have some expertise with SMA
or just a listing in general. There are parent networks and
organizations that do have listings of that.
Q.
We will be putting contact information for some of these parent
organizations and publications and resources that they may have
about health care insurance on our resource list on the web
site for people to look at. Well this has been a very interesting
conversation and I certainly have learned a lot and we discussed
about how complicated it is for families who have children with
special needs when they have to choose a health plan.
Q.
Kathy, do you have any other words of wisdom? I know you've
shared so much really good advice with us.
A.
The only thing I can suggest is just ask. Ask questions if you're
not sure about something. Know that it's your right as a parent
and as an insurance carrier that you can ask. Most of the time
if you ask questions, it's been my experience that people at
the insurance companies will answer with no problem. Also for
my child, we are the best resource and the best voice so to
speak for our child. These children are going to grow up and
be adults. They will still have these types of needs as they
are adults. That way too, it can help prepare them for when
they get out on their own, when they are an adult and what they
need to do for themselves because then they will have to speak
for themselves and this way we can help them.
A.
Very well said, Kathy. I agree with all of that.
Q.
So to summarize what we've gone over is you have to do your
homework and you have to be assertive. You have to keep records.
You have to identify professionals who can help you in navigating
the waters of raising a child with special health care needs.
There's a lot of information and a lot of helpful resourceful
and knowledgeable people out there who can help you. I want
to thank Robin and Kathy very much for sharing their expertise
with us. You're both extremely knowledgeable people and I'm
really grateful that you were able to participate in this webcast.
A.
Thank you very much for inviting me.
A.
Thanks for asking.
Q.
It's my pleasure. I look forward to hearing from you soon. Thank
you.
End
of interview.
