Insurance Information

 

*If you have questions or issues with your health care insurance, private or Medicaid we can assist you. We can also keep you updated and answer questions about the Health Care Reform’s Affordable Care Act. Please feel free to contact us.

*Medicare and Other Benefits and How They Work: Who Pays First
http://www.medicare.gov/Publications/Pubs/pdf/02179.pdf

Social Security Announces New Compassionate Allowances Conditions: view the press release (updated July 14th, 2011)

Medicaid and its Role for Children and Youth with Special Health Care Needs: A Family Perspective
http://ccf.georgetown.edu//index/medicaid-children-and-youth-with-special-health-care-needs

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Americans with Disabilities Act (ADA): Insurance and Benefits

Information from the U.S. Department of Labor concerning sections of the ADA that prohibit discrimination in employer-provided health insurance. To view, click here.

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Benefits.Gov
Delaware Medicaid and Delaware Healthy Children Program (SCHIP) benefits program details have recently been updated, and are now available:
Delaware Medicaid
Delaware Healthy Children Program (SCHIP) .

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Catalyst Center
The Catalyst Center is a national center dedicated to improving health care insurance and financing for  Children and Youth with Special Health Care Needs (CYSHCN). Visit their website.

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Centers for Medicare and Medicaid Services

On 12/30/10, the Centers for Medicare & Medicaid Services (CMS) enhanced the Physician Directory tool atwww.medicare.gov with new information about physicians and other healthcare workers in their communities and the services those professionals provide.

 The new feature, called Physician Compare, expands and updates CMS’ Healthcare Provider Directory, which has helped millions of beneficiaries find Medicare-participating doctors online for over a decade. The new tool expands the doctor-specific information into the suite of informational tools for Medicare beneficiaries and other consumers. 

“The new Physician Compare tool begins to fill an important gap in our online tools by providing more information about physicians and other healthcare workers,” said Donald Berwick, M.D., CMS administrator.  “This helps to pave the way for consumers to have similar information about their physicians as they have for nursing homes, home health agencies and health and drug plans.”

 The new site, at www.medicare.gov/find-a-doctor, which was required by the Affordable Care Act of 2010, contains information about physicians enrolled in the Medicare program, which include Doctors of Medicine, Osteopathy, Optometry, Podiatric Medicine, and Chiropractic. The site also contains information about other types of health professionals who routinely care for Medicare beneficiaries, including nurse practitioners, clinical psychologists, registered dietitians, physical therapists, physician assistants, and occupational therapists. 

 The Physician Compare Web Site is designed to be consumer friendly and help all patients—whether on Medicare or not—locate health professionals in their communities. The information on the site includes contact and address information for offices, the professional’s medical specialty, where the professional completed his or her degree as well as residency or other clinical training, whether the professional speaks a foreign language, and the professional’s gender.  The tool can also help Medicare beneficiaries identify which physicians participate in the Medicare program.

 In addition to information about the physician’s practice, Physician Compare also shows consumers whether the practice reported certain data to CMS through the Physician Quality Reporting System, formerly known as the Physician Quality Reporting Initiative (PQRI). Currently, the PQRI reporting system is a voluntary reporting program that rewards physicians and other eligible healthcare professionals for reporting data on quality measures related to services furnished to Medicare beneficiaries.  These quality measures are based on the best available medical evidence and designed to help professionals improve care for patients. In 2009, over 200,000 professionals reported data to CMS through the Physician Quality Reporting System.

Later in 2011, CMS plans a second phase of the Web site which will indicate whether professionals chose to participate in a voluntary effort with the Agency to encourage doctors to prescribe medicines electronically, rather than through traditional paper-based prescription methods.In future years, the Physician Compare Web site will be expanded with information about the quality of care Medicare beneficiaries receive from physicians and the other healthcare professionals profiled on the site.  The expansion will include information on quality of care and patient experience that can help consumers learn more about the care provided by Medicare-participating physicians.  CMS is required by the Affordable Care Act to develop a plan to implement this expansion by 2013.

 “Today’s release of Physician Compare moves us closer towards CMS’ goal to improve the quality of healthcare for people with Medicare in all the places where they receive care, including the doctor’s office,” said Berwick. “By using a considered, step-wise approach to spotlighting quality of care, we can create a tool that will help doctors and patients for decades to come.”

 CMS has been working closely with healthcare stakeholders as it develops its future plans for the Physician Compare Web site, and will continue to do so through public meetings and forums, as well as through the regular processes to update the Physician Fee Schedule. To learn more about the quality information CMS already collects through Medicare’s Physician Quality Reporting System, visit http://www.cms.gov/pqri.  To visit the Physician Compare Web site, visit www.medicare.gov/find-a-doctoror click on the Compare tab at www.healthcare.gov.

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CuidadodeSalud.gov:

The U.S. Department of Health and Human Services earlier this month
unveiled CuidadodeSalud.gov, the first website in Spanish of its kind to help consumers take control of their health care by connecting them to new information and
resources that will help them access quality, affordable health care
coverage. Consistent with the mandate in the Affordable Care Act,
CuidadodeSalud.gov is the partner site of HealthCare.gov, which was
launched in July 2010, and is the first website in Spanish to provide
consumers with both public and private health coverage options
tailored specifically for their needs in a single, easy-to-use tool.
Access the website to see how it works.

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Health Care Reform

Visit our health care reform page to view more resources.

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Insure Kids Now: Connecting Kids to Coverage
www.insurekidsnow.gov

Phone: 1-877-543-7669

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Kaiser Commission on Medicaid Facts
Medicaid and the Uninsured

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Medicaid Managed Care Plan

Medicaid: What if I Am Denied Coverage for Something That I Need?

If you have applied for or are receiving Medicaid benefits, you have special appeal rights. If you are in a managed care plan, you have the same grievance rights as those in managed care plans who are not receiving Medicaid. If you are in a managed care plan, you will also want to look at the articles, "How Can I File a Grievance in my Health Plan?" and "Can I Appeal the Health Plan's Denial to Someone Outside the Plan?"

If you are receiving Medicaid:

1. You have a right to receive written notice whenever you are denied Medicaid eligibility, a service or part of a service or coverage for something that you have requested. You must get written notice of an adverse action before it will take effect.
2. If you disagree with the denial, you have the right to appeal that decision and ask for a fair hearing in front of an administrative law judge.
3. If you ask for your appeal before the action would take effect, you have the right to have your coverage continue while you are appealing the decision.
4. Before the hearing, you have the right to review any documents in your case file as well as any documents that the State or county will use at the hearing.
5. You have the right to present witnesses, to be represented by someone else, and to present your case at the hearing.
6. If you lose your case at the hearing, you have the right to appeal the decision against you.

Have questions about your Mdicaid Managed Care plan? Join our Medicaid Managed Care Panel Teleconference. See our events page for the next teleconference and more information.

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Medigap: Choosing a Policy

Click here to learn more.

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Private Health Insurance:

Please click here to view many valuable resources on private health insurance.

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Pre-Existing Condition Insurance Plan

View a viedo that presents an overview of the Pre-Existing Condition Insurance Plan online application, providing assistance in what to expect, in addition to what information an applicant should have handy when ready to apply online at www.pcip.gov.

The Pre-Existing Condition Insurance Plan makes health insurance available to people who have had a problem getting insurance due to a pre-existing condition. 

The Pre-Existing Condition Insurance Plan:

• Covers a broad range of health benefits, including primary and specialty care, hospital care, and prescription drugs.
• Doesn’t charge you a higher premium just because of your medical condition.
• Doesn’t base eligibility on income.
• Fact Sheet and Premium
• Information on making this plan more affordable

A message from The National Family Caregivers Association:

 

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SCHIP State Snapshots: Delaware Healthy Children Program

More Information

United Healthcare Deadline: Open

The United Healthcare Children's Foundation (UHCCF) has announced that new grants are available to help children who need critical healthcare treatment, services, or equipment not covered or not fully covered by their parents' health benefit plans.

The foundation provides grants to families to help pay for child healthcare services such as speech therapy, physical therapy, occupational therapy sessions, prescriptions, and medical equipment such as wheel chairs, orthotics, and eyeglasses.

Parents and legal guardians may apply for grants of up to$5,000 each for child medical services and equipment by completing an online application at the UHCCF Web site.

http://www.uhccf.org/apply_applicant.html

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Common Questions
*These questions are pulled from various sources*

• Does my plan cover these services?
• Is there an annual deductable?
• What are co-pays?
• Is there an annual upper payment limit/cap or limit/cap on number of visits? What are lifetime limits/caps?
• Is there an annual limit for out-of-pocket expenses?
• What are the differences in cost between using a provider who is part of the plan and one that is not part of the plan?

• Physical examinations and health screenings.
• Care by specialists.
• Hospitalization
• Emergency care.
• Prescription drugs (see more detailed questions below).
• Vision care.
• Dental services.
• Care and counseling for mental health.
• Services for drug and alcohol abuse.
• Obstetrical-gynecological care and family planning services.
• Ongoing care for chronic (long-term) diseases, conditions, or disabilities.
• Physical therapy and other rehabilitative care.
• Home health, nursing home, and hospice care.
• Chiropractic or alternative health care, such as acupuncture.
• Experimental treatments.

• What preventive care is offered, such as shots for children?
• What health screenings are covered, such as breast exams and Pap smears for women?
• If the plan does not have a certain type of subspecialist in its network who is trained in the care of children, can I see an out of network pediatric specialist at no additional cost?
• What is the plan’s definition of medically necessary? (How/who determines medical necessity of services?)
• Are benefits, costs, etc different if traveling – out of state

Here are questions to ask to better understand a health insurance plan's pharmacy benefit:

• Does the plan require that doctor to choose drugs from a formulary, or list of covered medicines?
• If so, are the prescriptions that my family needs on the plan's formulary? If we need a medicine that is not on the formulary, will we have to pay for it myself, or will the plan reconsider its decision based on an appeal?
• What is the process for pursuing an appeal?
• How much are co-payments, or What do I owe the pharmacy when I get a prescription?
• Does the plan use a prescription mail order services? Is there a penalty if I don't want to use the mail order service? Will the plan require that I use it, or can I choose to get medicines at a local pharmacy?
• Is there a limit to out-of-pocket expenses? Does it include the amount I pay for my medications?
• Is there a cap (limit) on my total benefits? Is it possible that I could use up all my benefits and have to pay full price myself for anything else I need?
• If there is a less expensive medicine than the one my doctor prescribes, will the health plan require that the cheaper one is used first? (This is called step therapy.)
• Does the health plan ever call doctors to ask them to switch patients to a different, cheaper drug? (This is called therapeutic substitution.)
• Does the health plan require approval for certain medicines before it will pay for them? If so, how is this prior authorization obtained?

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Guide to Finding Health Insurance

Setting the Record Straight on Medicaid and Access