Tag: doctor

Help for Understanding Health Insurance

Posted on by Nicol Walsh

Healthcare insurance includes words and abbreviations that can be confusing and hard to remember. This article describes a few key terms to demystify the health insurance world for Washington State families. Washington Healthplanfinder.org is a place to research insurance options statewide, with English and Spanish options.

Managed Care Organization (MCO)

A Managed Care Organization (MCO) is an agency that coordinates medical services and reimburses providers.

State medical insurance in Washington is called Apple Health. Apple Health pays a monthly premium to an MCO that an individual or family chooses to manage preventive, primary, specialty, and other health services. Apple Health also pays for some services directly, through Fee for Service (FFS).

The term “provider” describes any health care professional or facility that provides treatment. Doctors, nurses, mental health professionals, physician assistants, dentists, therapists, behavior specialists, and many other professionals are considered providers.

Clients enrolled in managed care must seek providers who are part of their plan’s network unless there is an emergency or prior authorization is arranged. Prior authorization means the insurance company agrees to pay for a service, treatment, prescription drug, medical equipment, or something else because it is determined to be medically necessary.

The Apple Health system includes five MCOs. Not all plans are available in all areas of Washington State. ​

  • Amerigroup (AMG)
  • Community Health Plan of Washington (CHPW)
  • Coordinated Care of Washington (CCW)
  • Molina Healthcare of Washington, Inc (MHW)
  • United Healthcare Community Plan (UHC)

For complicated circumstances, an MCO may recommend a case manager be assigned to support an individual’s care. Families also have the option to request case management, especially if locating providers is difficult to meet unique or substantial needs.

Health Maintenance Organization (HMO)

A Health Maintenance Organization (HMO) is a type of MCO.  An HMO is an independent system that requires enrollees to seek care within a specific network of hospitals and providers. An HMO plan is based on a network of providers who agree to coordinate care in return for a certain payment rate for their services. 

Preferred Provider Organization (PPO)

A Preferred Provider Organization (PPO) is another type of MCO. A PPO generally will allow individuals to choose their providers and does not limit reimbursement to providers in a specific network. Because of that, a PPO tends to be more expensive than an HMO.

What is the difference between Medicaid and Medicare?

Medicaid is income dependent, and Medicare is not. Both provide government-funded healthcare.

Medicaid is state-managed to provide free or low-cost medical coverage for individuals or families who qualify based on income. Washington’s Medicaid program is Apple Health.

Medicare is a federal health insurance program for individuals age 65 and older and for those with qualifying disabilities. Medicare is not dependent on income.

Copayments, Premiums, and Deductibles

When healthcare is not free, the cost to the family adds up through the copayments, premiums, and deductibles. Here’s what that means:

  • Copayment: a specific fee for a visit or procedure.
  • Premium: payment for the insurance. An individual might have premiums withheld from a paycheck, or an employer might agree to pay all or part of the premium.
  • Deductible: the amount of money an individual must pay each year before insurance payments “kick in.” After a deductible is met, the patient may still make copayments or pay a percentage of the cost, depending on the plan. Supplemental insurance through Medicare is sometimes an option to cover deductible expenses.

What is a Medicaid Waiver?

A Medicaid waiver allows the federal government to waive rules that usually apply to the Medicaid program. The intention is to reimburse for services that would not otherwise be covered by Medicaid. Waivers generally provide local, non-institutional solutions for individuals with disabilities. For example, in-home care paid for through a waiver might support someone to live in the community.

Medicaid.gov provides a Washington Waiver Fact Sheet that outlines waiver programs available in Washington State.

An Illustration of the insurance terms described in this document

Download the illustration as a PDF – Health Illustrative

Technology Provides Options for Medical Care from a Distance

Posted on by Nicol Walsh

A Brief Overview

  • During the coronavirus pandemic and statewide stay-home orders, some providers are offering online appointments. This article includes information about access to telehealth and how to prepare for a virtual visit.
  • Federal privacy laws have been relaxed during the shutdown to allow more opportunities for on-screen healthcare. Washington’s telemedicine parity law was updated by the 2015 legislature. Those updates went into effect in 2017 (SSB 5175).
  • Generally, military families with TRICARE and families with state insurance, Apple Health, have coverage for medically necessary services provided through telemedicine.
  • A 6-minute video tutorial from the Hawaii Department of Health provides information about what to expect during a telehealth session.
  • Washington’s Department of Social and Health Services (DSHS) is providing free cell phones and minutes to low-income families through a federal program called Lifeline. State-specific information about this option is available from the Health Care Authority.
  • See Links to Support Families during the Coronavirus Crisis for additional resources.

Full Article

Families staying home during the coronavirus pandemic need new ways to access medical care. Onscreen appointments—telehealth, telemedicine, teleintervention, telepsychiatry—meet some needs.

The U.S. Department of Health and Human Services (hhs.gov) in early March 2020 relaxed legal requirements related to confidentiality in order to support the delivery of telehealth services while families shelter in place. Roger Severino, director of the Office for Civil Rights (OCR), issued the following statement: “We are empowering medical providers to serve patients wherever they are during this national public health emergency. We are especially concerned about reaching those most at risk, including older persons and persons with disabilities.”

The federal guidance refers to confidentiality rules under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The HHS website states that OCR will use discretion and relax compliance under HIPAA if services are delivered in good faith:

“During the COVID-19 national emergency, which also constitutes a nationwide public health emergency, covered health care providers subject to the HIPAA Rules may seek to communicate with patients, and provide telehealth services, through remote communications technologies.  Some of these technologies, and the manner in which they are used by HIPAA-covered health care providers, may not fully comply with the requirements of the HIPAA Rules.”

Washington State has grown telehealth since 2015

Even before social distancing requirements, virtual appointments for diagnoses and treatments that don’t require direct physical examination have gained popularity. Before COVID-19 took hold, Washington’s 2020 legislature passed HB 2728 to support further development of children’s behavioral health services delivered through telemedicine.

In order to meet needs in some rural communities and underserved fields, such as psychiatry, Washington’s telemedicine parity law was updated by the 2015 legislature. Those updates went into effect in 2017 (SSB 5175).

The law enables providers to seek reimbursement for most services provided virtually if those same services would be covered by insurance if they were delivered in person. The law defines telemedicine as “the delivery of health care services through the use of interactive audio and video technology, permitting real-time communication between the patient at the originating site and the provider, for the purpose of diagnosis, consultation, or treatment.”

Telephone (“audio only”) services or provider guidance by facsimile (FAX) or email may not be covered. Families can check with their insurance carrier to make sure an appointment would be covered if video could fail during the appointment or is unavailable because of a technology complication.

Generally, telemedicine is covered by insurance if:

  • The payor would cover the service if it was provided in-person, and the service can reasonably be provided without direct contact.
  • The health care service is medically necessary.
  • The service is recognized as an essential health benefit under the federal Patient Protection and Affordable Care Act

Individual providers create their own policies about whether they provide services electronically, and the parity law doesn’t guarantee equal reimbursement. Washington is part of the Interstate Medical Licensure Compact, making it easier for providers to get licensed in multiple states and provide services to a broader clientele, including through telemedicine.

Families with Medicaid in Washington State, which is called Apple Health, can find information related to telehealth from the Health Care Authority. In keeping with federal guidance, Medicaid in general is reimbursing telehealth services at the same rate they would reimburse in-person services during the pandemic.

TRICARE expands options for military families, including ABA

TRICARE provides coverage for medically necessary telemedicine visits from providers who offer that service. Preventive health screenings, psychiatric care and medication consultations are examples of appointments that are most easily held virtually. Depending on the TRICARE plan, an authorization or referral may be needed.

In addition, TRICARE is extending telehealth for families who access Applied Behavior Analysis (ABA) and are enrolled in the Autism Care Demonstration (ACD) March 31- May 31, 2020. This temporary extension includes ABA support to parents/caregivers, and the services don’t require the child to be present at the telehealth appointment.

How do I prepare for a telemedicine appointment?

Before services are rendered, providers are required to seek informed consent from patients and/or legal guardians and to provide information about how the technology works and how privacy is protected. Electronic signatures are generally acceptable, particularly as the state requires social distancing. The Washington State Department of Social and Health Services (DSHS) provides a downloadable guidebook about telehealth. 

Prepare for a routine check-up like you would if you were visiting the clinic: Write down questions and concerns, including any changes related to health or medication. A visual tutorial, created by the Department of Health in Hawaii, walks through the different types of telehealth and what someone might expect.

If you suspect COVID-19, carefully document symptoms. The Centers for Disease Control (CDC) provide a COVID-19 screening tool. Be sure to note anything about the illness or its possible treatment that might be affected by a disability condition.

If testing is prescribed, a drive-through testing site may be suggested. The Americans with Disabilities Act (ADA) affords individuals the right to accommodations when accessing what is publicly available. The Northwest ADA Center provides guidance about drive-through testing, specifically addressing topics related to blindness, deafness or wheelchair access, for example. Prepare for the telehealth appointment with any questions related to drive-through testing and disability, if that topic might come up.

What if I don’t have internet or a cell phone?

Families who do not have internet at home may be able to get service for free or low cost because of the pandemic. Some internet providers offer free internet for a limited time, based on income. Internet Essentials from Comcast and Charter Communications are examples. Their services are based on income, and students with free and reduced lunches are among those who may qualify.

Washington’s  Department of Social and Health Services (DSHS) is providing free cell phones and minutes to low-income families through a federal program called Lifeline. State-specific information about this option is available from the Health Care Authority.

How can I plan for an in-person doctor visit or emergency?

Children with complex medical needs may still need an in-person doctor visit for some conditions. General guidance is to call ahead if there is concern that anyone in the family might be ill so medical staff can take precautions to protect everyone from exposure to illness. In many locations, individuals are screened and checked for fever before they enter the facility.

For a medical emergency, prepare to offer first-responders clear information about the nature of the emergency. If a member of your household has a chronic condition that may create an urgent care situation, prepare a handout with basic information in advance. PAVE’s article about a Care Notebook might help. Because personal protective equipment (masks, gloves, gowns) are in short supply, responders will send minimal staff for less urgent circumstances. If the situation is clearly life or death, a larger team may suit up with personal protective equipment in order to help.

Many dental offices have closed, although some may remain open for emergency procedures. Call ahead: Schedules and policies are changing rapidly.

Caregivers of children with complex needs face additional challenges

Being the caregiver for a child with significant medical needs adds additional layers to current circumstances. Here are questions some will face:

  • Is my child’s medical need worth the risk of exposure to a hospital setting?
  • What are the short-term and long-term considerations in changing the plan for care during this time of national crisis?

The answers obviously are personal and different for every family’s circumstances.

While facing tough choices and uncertain times, your self-care is critical, and PAVE offers an article with ideas just for you. Of course, start with the basics: breathe with intention, nourish your body and seek points of fun and connection each day. Staying connected to a child’s care team can help, so you’re already in touch if there’s an emergent medical situation.

PAVE’s Family-to-Family Health Information Center continues to provide information for families and caregivers of children with disabilities and special healthcare needs in Washington State. Fill out a Helpline Request Form at wapave.org for individualized assistance.