When choosing coverage for your current health care needs, it’s vital to know what doctors, clinics, hospitals—and access to other providers and medical groups—the plans available to you include. Are there clinics conveniently located near where you work and live? Can you get next-day appointments? Can you see top specialists when necessary?
For instance, Physicians Plus Insurance:
•Partners with Meriter Health Services, many UW physicians and clinics, and independent doctors and clinics like Associated Physicians, Wildwood Family Clinic, Access Community Health Centers, Madison Women’s Health, Wingra Family Medical Center, and Melius, Schurr & Cardwell Physicians for Women
•Offers access to two Madison urgent care centers, two after-hours pediatric clinics, and 24 network hospitals in south-central Wisconsin.
•As of 2013, will expand access to additional centers of excellence, including Mayo Clinic, Children’s Hospital of Wisconsin, and Froedtert Hospital/Medical College of Wisconsin
about 90% of its 105,000 members’ care. “For the roughly 10% of care Meriter’s integrated delivery system can’t provide—such as transplants and some burn, cancer and pediatric treatments—we’ll work with patients and their doctors to get them the highest quality of care at the lowest cost, including at UW Hospital,” says Linda Hoff, president of Physicians Plus Insurance. “We expect most care to stay local and anticipate this program will save $20 million to $30 million a year, resulting in substantially lower rates and premiums.
“Local doctors founded our organization in 1986 with the principle of providing the best possible care for the lowest possible cost,” she adds. “Local doctors still own the organization and that’s still our goal. We’re committed to providing extraordinary community health care and unmatched access to primary care—we encourage members to visit their doctors regularly so we can catch small medical issues before they become big ones.”
The plan you choose should also ensure your health care is coordinated rather than fragmented. Physicians Plus is launching a 2013 initiative, care navigation, to enhance the collaborative nature of its health care. “It’s a means of helping patients get the right care from the right doctor and facility at the right time. Care navigation is a best practice in many other markets that improves care and reduces costs,” explains Hoff. “Members’ primary care physicians will guide them to high-value specialty care within our integrated delivery system.”
Make sure your provider treats you as a partner in your own health care. “We keep people actively engaged in their care, which helps control costs,” Hoff says. “And we use all data at our disposal to help physicians and patients choose the most effective doctors and treatments.”
Provider organizations should also offer programs and technologies to help you stay well. Physicians Plus:
•Provides financial incentives for healthy activities, such as joining a gym, taking a wellness class, or buying a community supported agriculture (CSA) share.
•Its Go-To website gives secure access to your personal health plan information.
•Its RxManager mobile app lets you research prescription information and access your own records.
•The MobileNurse app answers questions that help you make health care decisions.
•NursePlus provides toll-free phone access to a registered nurse 24/7.
And be sure your provider continually comes up with ways to provide better care more affordably. “We’re reducing paperwork, encouraging healthy lifestyles, and developing better preventive, diagnostic and treatment options,” says Hoff. “Health care isn’t just a business; it’s part of our commitment to better health for everyone in the community. Having a healthier community lowers costs for everyone.”
Tom Moreland, owner and CEO of Saint Jude Hospice, headquartered in Des Moines, Iowa, is a big proponent of long-term care (LTC) insurance. “It helped my grandma a lot when she needed home health care and then was placed in a facility. It paid for that,” he says.
Medicare doesn’t pay for assisted living or nursing homes, and doesn’t cover hospice care until you reach age 65. And as the National Clearinghouse for Long-Term Care Information website (longtermcare.gov) notes, there’s a good chance you’ll need some LTC services if you live beyond the age of 65. Almost 70% of people over 65 do.
“A lot of people think Medicare pays for LTC, but it doesn’t,” says Moreland. “It does pay for a short nursing home stay after a three-day hospital stay. After that, without LTC insurance you have to use your own assets until they’re depleted. Then Medicaid kicks in at facilities that accept it.”
Saint Jude Hospice’s core business is working with people—in their homes or in facilities—who have prognoses of six months or less of life. “We give physical, psycho-social and emotional care,” says Moreland. We have an office in Madison and a satellite office in Baraboo, and we recently opened a support center in Platteville so we can more easily provide care to southwest Wisconsin. Our team in that area, including a full-time nurse and caregivers, keeps supplies and everything they need there.”
Everyone is entitled to Medicare Part A, which pays for hospice care at age 65, Moreland says, but it still doesn’t pay for home care or an LTC facility. So he’s seeing more people choose LTC insurance.
“It’s a great idea, with 10,000 boomers turning 65 every day,” he says. “More facilities are filling up and are more likely to take LTC insurance than Medicaid, so insurance gives you a better chance of getting in the facility of your choice.”
Some LTC insurance plans do pay for hospice care before you’re 65. “Make sure you pick a plan that has adequate home-care and hospice benefits,” emphasizes Moreland.
As the LTC clearinghouse site notes, most consumers don’t know they must “health qualify” for LTC insurance. “There’s a saying: Your money pays for long-term care insurance, but your health buys it. Your health is the single most important factor.”
The American Association for Long-Term Care Insurance (AALTC) provides some statistics:
•Fewer than one in 10 of those younger coverage
•45% of those ages 70 to 79 are rejected
Also, premiums for LTC insurance are based on your age when you apply and costs increase on your birthday. The AALTC reports annual rate increases are generally 2% to 4% percent in your 50s, but 6% to 8% in your 60s.
When you research LTC insurance, look at the reimbursement rates for LTC, home care and hospice care. And know that facility rates will increase over time. “Call LTC and hospice organizations and ask about their chargeable rates to see if the policies will cover them,” advises Moreland.
“A lot of people buy lower LTC policies that pay 50% or 80%, and they think they’re going to be covered 100%. There may be a gap between billable rates at hospice and what the insurance will pay,” he adds. “If it’s small, you may be able to negotiate with the organization to take a lower rate—we’re willing to do that.”
Saint Jude’s social worker helps people negotiate the LTC world. “That’s a big part of the job—as well as being a friend and a help to the family, our social worker is also a huge resource and knows the insurance system very well,” says Moreland. “We help get people placed and work directly with LTC insurance carriers to get reimbursements, so the families don’t have to.”
– Judy Dahl