Lymie is Lyme and the City's newest blogger and will be providing fast facts about Lyme Disease in a series of blog posts called:
"Notes from Lymie"
I made this Lyme Disease symptoms graphic as part of a new infographic I am hoping to make in the near future... Pin Away!
DO YOU KNOW WHETHER YOUR INSURANCE PLAN IS FULLY-FUNDED or SELF-FUNDED?
THE DISTINCTION MATTERS!
Please keep in mind that this post is not intended to be legal advice. Please check my disclaimers section if you need a refresher!
Before I explain why the distinction is of critical importance, let me lay out the fundamental differences between the two. Traditionally, health insurance plans have been fully-funded.
The basic mechanics of a fully-funded plan are as follows:
1. EMPLOYER PAYS PREMIUMS TO INSURANCE CARRIER--The company (i.e., usually your employer) pays a premium to the insurance carrier (think: UHC, Aetna, Cigna etc.) for the cost of providing a fully-funded insurance plan to the employer's covered persons (e.g., employees or dependents).
With fully insured health insurance plans, employers pay an insurance provider in advance to cover projected claims, the financial risk associated with funding the insurance plan, in addition to the insurer’s overhead and administrative costs.
2. FIXED RATES FOR EMPLOYER--The premium rates that an employer pays the insurance carrier for the insurance plan are fixed for a year, based on the number of employees enrolled in the plan each month. In other words, the employer pays the same monthly premium no matter what their employees' individual claims are. The monthly premium only changes during the year if the number of enrolled employees in the plan changes.
3. INSURANCE CARRIER ADMINISTERS PLAN--The insurance carrier administers the plan. The insurance carrier collects the premiums from the employer and pays the health care claims based on the coverage benefits outlined in the insurance policy purchased.
4. SUBJECT TO STATE REGULATION--They are subject to certain state health insurance regulations and benefits mandates.
A self-funded, or self-insured plan, on the other hand, is one in which the employer assumes the financial risk for providing healthcare benefits to its employees.
The basic mechanics of a self-funded plan are as follows:
1. EMPLOYER HAS CONTROL OVER DESIGN OF PLAN--The employer has significant say into the design of the medical benefits plan. Plan types may either mirror fully insured benefit models or can be adapted to meet the specific needs of a member population and budget, through a customized suite of benefit and product options.
2. EMPLOYER HAS CONTROL OVER COST OF PREMIUMS--The employer can set the premium rates based on their claims history and adjust the plan in other ways to cut costs. If claims are lower than anticipated, the employer can invest any savings and earn interest. In the event that claims are higher than usual, stop-loss insurance coverage can pay for excess costs (see discussion below.
3. EMPLOYER FUNDS MEDICAL CLAIMS DIRECTLY--Rather than obtaining medical coverage from an insurance carrier, the employer funds the risk directly from the employer's assets. The employer becomes directly responsible for benefits covered under the plan. In a self-funded plan, the money collected by the organization is only paid out when claims actually occur. In other words, the employer essentially pays claims out-of-pocket from the collected premiums of its employees rather than using predetermined premiums to compensate an insurance provider for assuming financial risk.
4. PLAN NOT SUBJECT TO STATE REGULATION, ONLY FEDERAL--State regulations mandating benefits are optional because self-funding is regulated by federal legislation only. The federal regulations that usually apply are:
- The Employee Retirement Income Security Act (ERISA)
- The Health Insurance Portability and Accountability Act (HIPAA)
- The Consolidated Omnibus Budget Reconciliation Act (COBRA)
- The Americans with Disabilities Act (ADA)
- The Pregnancy Discrimination Act
- The Age Discrimination in Employment Act
- The Civil Rights Act
- Various budget reconciliation acts such as Tax Equity and Fiscal Responsibility Act (TEFRA), Deficit Reduction Act (DEFRA), and Economic Recovery Tax Act (ERTA)
5. EMPLOYER MAY PURCHASE STOP LOSS INSURANCE--Stop loss insurance may be arranged to limit the employer's loss to a specified amount and ensure that catastrophic claims do not upset the financial integrity of the self-funded plan.
6. EMPLOYER MAY CONTRACT PLAN ADMINISTRATOR--The employer may administer the insurance plan itself, but more than likely it will contract a Third-Party Administrator ("TPA" or "Plan Administrator") to do so. TPAs can be management companies such as Zenith Administrator or CoreSource or they can be insurance companies like UHC, Blue Cross Blue Shield etc.
The TPA will be named in your insurance plan document (usually the Summary Plan Description) as the "Plan Administrator" and your employer will usually be named as the "Plan Sponsor".
Keep in mind, two people may have insurance through United HealthCare, for instance, but this doesn't mean they have the same fully-funded plan, or that one of them might actually have a self-funded plan where United HealthCare is just the TPA.
7. PREPARATION OF SUMMARY PLAN DESCRIPTION--A Summary Plan Description (SPD) is prepared (usually by the TPA) and distributed to covered employees. The SPD contains all the provisions of the plan, including eligibility, coverage descriptions and plan exclusions and limitations. The TPA typically prepares the plan booklets, ID cards, provider directories and other employee materials.
8. TPA ADMINISTERS PLAN--Its responsibilities include maintaining eligibility, adjudicating and paying claims and appeals, customer service, utilization management, preparing claim reports, plus arranging for services such as provider network access and implementation of a Pharmacy Benefit Management program.
NOW LET'S TALK ABOUT WHY THIS DISTINCTION MATTERS TO YOU!
1. IT MAY CHANGE CRITERIA FOR BENEFITS--Because self-funded insurance plans have the ability and flexibility to delineate what benefits it will cover, they may have an entirely different set of criteria for determining when a medical claim or prescription is covered. Often the criteria is very different from the one the TPA customarily uses when administering its fully-funded plans.
This means that if the TPA is using their own criteria, as opposed to the criteria of the self-funded plan, you may have a viable claim of action and should seek legal counsel!
Note, that under ERISA, you are generally entitled to receive a copy of any criteria, guidelines or protocals that a TPA used to make a medical claim decision--make sure you ask for any documentation related to the insurance company's denial!
Generally, you may accomplish this by calling the customer assistance line noted on the back of your insurance card and requesting it. They may direct you to send your request in writing and you should do so.
2. IT CAN EFFECT YOUR RIGHT TO AN EXTERNAL REVIEW OF DENIALS--Depending on the type of insurance plan you have, you may be entitled to up to two levels of appeal or review directly with your insurance company. In addition to this, some states provide employees the right to an external appeal usually with an Independent Review Organization.
However, the right to an external appeal only applies to fully-funded plans--you do not have a state mandated right to an external appeal if your plan is self-funded.
Instead, you must file your claims under the applicable federal regulations. Usually this is a claim under ERISA, which I plan to discuss in future posts.
3. IT CHANGES THE COURT YOU CAN BRING LAWSUITS IN AND THE CLAIMS--The employer can set the premium rates based on their claims history and adjust the plan in other ways to cut costs. If claims are lower than anticipated, the employer can invest any savings and earn interest. In the event that claims are higher than usual, stop-loss insurance coverage can pay for excess costs (see discussion below.
4. IT CHANGES WHO HAS THE FINAL SAY--With self-funded plans, employers have the right to override denials made by the TPA! It may do so on an individual, case by case basis or it may revise the entire plan to apply to all covered employees!
This means that if you keep getting denied by the insurance company, you should appeal directly to your company.
I think that it is generally good practice to jump through all of the hoops the insurance companies make you go through before making an appeal directly to your employer.
5. IT MAY PROVIDE A HAIL MARY PASS FOR PLAN EXCLUSIONS--Often times, insurance companies will not actually deny your claim or medication, but rather will say that it is a plan exclusion or a benefit that is not covered. There are situations where you may be able to litigate about the poor drafting of an exclusion or the TPAs failure to comply with certain regulations, but there may be an easier solution! Remember that employers have the ultimate say in self-funded plans--this means they have the power to cover a benefit that is a "plan exclusion"!
SO WHAT'S THE MORAL OF THE STORY?
Before giving up, talk to the HR/Benefits department of your employer! It is sometimes a very easy conversation that leads to a quick phone call on their part to the insurance company or TPA to cover your excluded benefit.
And yes, it DOES happen!
I hope this was helpful! Please let me know if you have any additional tips or thoughts! Are there other things you don't understand that you would like to learn more about? Message me!
Is your doctor out-of-network? Does your doctor not accept insurance?
If so, here is a quick step-by-step guide to submitting a medical claim to your insurance company for reimbursement!
Again, this is not legal advice--just advice based on my personal experience.
1. OBTAIN A SUPERBILL FROM YOUR PROVIDER--If your doctor does not automatically provide you with a "superbill" or routing slip, ask for one! If you didn't get one at the time of your appointment, call the office and have them send you one. In addition, keep a copy of your credit card receipt.
2. COMPLETE YOUR INSURANCE COMPANY'S MEDICAL CLAIM FORM--Your insurance company will have a form (sometimes called a medical claim form, other times called a health claim transmittal form) that you need to submit in order to submit your medical claim for reimbursement.
Usually, you can find this if you log into your insurance provider's online portal. You can also call the service number on the back of your insurance card and they will direct you to the right form. Do not just google "Aetna Medical Claim Form"! The same insurance provider (i.e., UHC or Aetna) may have different variations of the form depending on your plan. Make sure you are submitting the correct one!
3. WRITE A LETTER--Write a letter to the insurance company at the address you are required to submit the medical claim form. A simple example letter might read:
Re: Medical Claim Form Related to Services Rendered by [Dr. XYZ] on [Date of Service] Member: [Name] Member ID No.: [#] Group No: [#] Provider: [Name of Doctor] Date of Service: [Date You Were Seen by Doctor] Amount Billed: [$ Amount You Were Charged] To Whom It May Concern,
Attached please find a signed medical claim form related to serviced rendered by Dr. XYZ on [Date of Service]. In addition, please find a copy of the related superbill and credit card reciept in the amount of [$]. As set forth under the terms of my plan, please reimburse me for this cost and credit my account and deductibles accordingly.
- A signed copy of the Medical Claim Form dated [X]
- A copy of a superbill for services rendered by Dr. XYZ on [date].
- A copy of a credit card reciept dated [X] in the amount of [$]
4. MAKE LABELS AND STICK ON EVERY PAGE--Make labels that include the information set forth below:
Member: [Name] Member ID No.: [#] Group No: [#] Date: [Date ]
Put this on EVERY SINGLE PAGE. Yes, even the page with the copy of the receipt. Yes, even pages that might already have that information. Note, do NOT cover up any words or information.
If you can't find a blank space, put the sticker on the back (and make a double sided copy). The reason I do this is because sometimes insurance companies require you to put this information on every page you submit, but often this requirement is in teeny, tiny writing in some obscure place - don't give them any excuse to deny your claim! As an additional perk, it will make your life easier if you have to appeal because your forms and documents will be more organized and better labeled (trust me, the dates and forms get mixed up pretty quickly).
5. MAKE HARD COPIES AND SCAN--Once you have signed the letter, put labels (or written that information) on every page, verified that you have completed the correct form and have the correct address, make a copy of the entire package. File that away somewhere safe. I prefer to create a binder, but will do a separate post on that! In addition, scan the entire package into a single PDF so that you can easily access an electronic version.
5. FOR BEST RESULTS, SEND CERTIFIED MAIL--Sending your medical claim form and supporting documentation via certified mail is not necessary. Perhaps it is just the lawyer in me who is a bit risk averse, but sending certified mail just rids the insurance company of the excuse that they never received it. Keep the signed green form when you get it back and file it away!
I hope this was helpful!
If you have any other tips or suggestions, please write me!
A special thank you to my mother and two little birdies from the office who help me coordinate to send all these things out!
I hate to admit that it wasn’t until recently that I fully understood the difference between in-network and out-of-network. I wish I could blame my parents for my ignorance, but every time I went to a doctor my parents diligently harassed me about whether or not I checked to see if the doctor was in-network.
In my defense, my parents coddled me a bit. They always saved me if I carelessly ended up with a bill from an out-of-network provider. They very literally, paid for my mistakes.
This changed, however, when I graduated from law school and became a “real adult”. The ink on my diploma wasn’t even dry before my parents promptly kicked me out of the cozy nest of financial backing I had grown accustomed to. It was time for me to fly.
Soon I was responsible for filing my own taxes, shelling out an ungodly amount for my tiny studio in Gramercy, and paying for my own insurance and medical bills. Although, now that I think about it, they still pay for my cell phone bill. Maybe they won’t notice until my next pay raise…
Up until this point, everything was going according to plan— I was busy “lawyering” and doing big girl things. Then Lyme happened. It wasn’t long before the medical bills piled up and these bills were from doctors who were “in-network”. But Lyme doesn’t make things easy—it is not for the weak.
Lyme handed me another twist: most LLMD’s are out-of-network or “don’t accept insurance”. I knew seeing an LLMD would cost me much more, but I desperately needed someone who knew, really knew, about Lyme.
Although I would pay almost anything to get my life and health back, I never stop getting sticker shock when I realize that just one office visit will run me $900 out-of-pocket. It doesn’t take too many visits before you are several thousand dollars deep in medical bills.
That’s when I realized I needed to get informed. What does out-of network really mean? Is that different from a doctor “not accepting insurance”?
To my understanding, insurance plans contract with a wide range of doctors, as well as specialists, hospitals, labs, radiology facilities and pharmacies (collectively referred to as “Providers”). Each of these providers has agreed to accept your insurance plan’s contracted rate as payment in full for services. These are “in-network” providers.
Thus, an out-of-network provider is a doctor who has not agreed to any set rate with your insurer, and may charge more. This means you may have higher co-pays, deductibles and other costs associated with out-of-network care. Further, your plan may not cover out-of-network care at all, leaving you to pay the full cost yourself.
This does not mean, however, that they won’t take your insurance information and bill the insurance company directly—it is very possible to go to a doctor and never realize they are out-of-network.
So, is out-of-network synonymous with “not accepting insurance”? Yes and no. Doctors who do not accept insurance are “out-of-network”, but they are distinct in that they will not submit the bill to the insurance provider.
It is important to note, however, that this does not prevent you from submitting the bill to the insurance company yourself.
In fact, it is critical that you do so as some insurance companies have deadlines for submitting bills for reimbursement. Under my policy, I must submit a “Health Claim Transmittal” form along with a copy of my “superbill” or “routing slip” (a detailed bill for your visit that includes procedure codes and a breakdown of the charges).
For good measure, I include a copy of my credit card receipt and write a letter that includes all of my identifying information, the date, and the list of enclosures. Including a letter, in my opinion, is important. It creates a record of correspondence with the insurance company regarding the claim. I plan to write more about that soon.
I also created labels with my name, member ID, group number, employer and date. I place one on every single page that I submit to the insurance company so there is no doubt about when a document is received.
Finally, I make a copy of EVERYTHING: my signed letter, the form, all of the bills and receipts. I also scan a version and keep it in a folder titled “Letters to Insurance Company”. To be clear, this does not mean the insurance company can’t or won’t deny a claim—I save appeals for another day.
But, they can’t deny a claim that you never submit. I know it’s really hard to work up the energy to deal with insurance reimbursements when you are sick. It’s overwhelming even for the average, healthy person.
Check to see if your employer offers services like "HealthAdvocate". These services, among other things, will coordinate your medical claims or work to reduce your medical bills.
Sometimes your employer has programs that aren’t widely publicized—do yourself a favor, shoot the HR/Benefits person an email and just ask.
In the end, asking a couple questions and submitting a couple forms could save you thousands of dollars. Money you could spend buying Paleo-friendly groceries, buying your friends a copy of “Under our Skin” or just going shopping to “treat yo self”!
Again, nothing in this post is intended to be legal advice. It’s just my thoughts as I go through this process myself. If you have any tips or advice, write me—I want to hear it all!
There are a couple things in this world that will make me feel better no matter how terrible I am feeling: (1) fresh flowers, (2) anything related to Frida Kahlo and (3) puppies.
But, when a puppy can adequately convey what it's like to have Lyme well it's almost just too much!
This puppy seems like he is going through the same feelings I do when I try to wake up in the morning--something that seems almost impossible with Lyme.
For anyone who has ever had the misfortune of trying to get me up... Do I look this cute?
Please say yes.
I never thought that part of my journey in recovering from Lyme would include writing a letter to the Governor of New York. I typically leave protesting injustices to the other Berkeley Law alums.
But, day after day, I found myself complaining about the same things... How painful the process was to get diagnosed, how impossible it was to find a doctor, how expensive the treatments are, and how clueless the world is to the severity of Lyme Disease.
I was growing increasingly angry and helpless. Then one day I ran across a news article about a piece of New York legislation on Lyme. It mentioned that this legislation had passed both houses and was currently in front of Governor Cuomo.
Ultimately, Governor Cuomo would decide whether or not this legislation would become law. Just one signature could change the legal landscape of Lyme, or at least be a step in the right direction. But, politics never interested me. I never had much faith in the process.
I was scared to put in the time or energy, just to find out that I never even had a chance to influence the outcome in the first place. I decided to reach out to one of my best friends from law school. He had made a career in politics before turning to law and I knew he would tell me honestly if writing a letter was futile. I prepared myself for disappointment, I readied myself to hear that my letter would likely be tossed into the nearest trash.
Instead, my friend explained that few people actually take the time to write to government officials, so one letter is often considered the voice of many more--he encouraged me to write the letter. In fact, he was so insistent that I write it that when I would drag my feet in drafting it, he would email and text me to get on my case to just finish it.
Then one day he called my office (which he never does) to tell me that he realized he knew a colleague who worked at the Governor's office. He urged me to hurry up and finish my letter so that he could pass it along--he had been told that the Governor would be making a decision that month.
His colleague didn't promise anything, just that he would read my letter. But, that was all I needed to hear: I had an opportunity. A small window of opportunity to matter.
I knew it was now or never--I had to write this letter, if only to know that I wasn't one to just complain without taking action. I did my best to try and encompass the myriad of issues surrounding Lyme into a succinct, one page letter (which involved adjusting the margins and font size quite a bit!). I also included a list of all of my symptoms, medications and supplements, hoping that the Governor's office would be able to "see" what it was like to have Lyme.
Even still, I didn't hold my breath that my letter would actually get read, much less that the bill would get signed. Weeks passed and I didn't hear anything else about the legislation or my letter. I had almost forgotten about it when I received an email that the Governor had made his decision.
To my utter surprise, Cuomo signed the Lyme legislation! I instantly sent my friend a text message relaying the good news, but he already knew. In fact, he told me that he had spoken to his colleague at the Governor's office about it.
His colleague mentioned that my letter and the lists I sent helped humanize the issue--something that doesn't always happen. I have no idea if that is actually true or not, but it made me feel as though my voice had mattered for once. That someone had listened.
In fact, it made me cry. I cried because I am blessed to have the type of friends who do these things for me, who help me get my letters read. I cried because the Governor signed the bill. I cried because maybe my letter had mattered, even if only in some small way. I cried because I hate Lyme disease for all the things it takes away from you. What often seems like everything...
But remember, Lyme disease can't take away everything: Lyme Disease cannot take away your hope or your will to keep fighting. Only YOU can do that. Only you can decide to give up, to be hopeless, to throw your hands up in defeat because it seems too hard. Too unfair.
When it comes to Lyme, you have two choices: drown in the injustice of it all or find some deeper meaning that helps you stay afloat. To not just find the light amidst all the darkness, but BE the light.
If you are feeling sick or discouraged or fed up, do something small. You'll feel less helpless. Less alone. Less frustrated.
Maybe you'll get lucky and someone will listen...
A special thank you to a little birdie in DC. Thanks for being the best mock trial husband a girl could ask for and for being such a wonderful friend.
I would also like to thank Governor Cuomo's office for taking the time to hear the story and plight of this New Yorker with Lyme. Even if the outcome had not been favorable, feeling as though I had a legitimate voice in the process is more than I could have asked for.
Inspired by a recipe in the Paleo book "Well Fed", this Chocolate Chili is an easy way to get an extra dose of turmeric!
- 2 pounds lean ground beef or turkey
- 2 tablespoons coconut oil
- 1 can (6 ounces) tomato paste
- 1 can (14.5 ounces) beef broth
- 1 can (14.5 ounces) fire-roasted, chopped tomatoes
- 2 medium onions, diced (about 2 cups)
- 4 cloves garlic, minced (about 4 teaspoons)
- 1 teaspoon dried oregano leaves
- 2 tablespoons chili powder
- 2 tablespoons ground cumin
- 1 1/2 tablespoons unsweetened cocoa
- 1 teaspoon ground allspice
- 1 teaspoon salt
- 2 teaspoons espresso seasoning
- 1 teaspoon Turmeric
Heat a large, deep pot over medium-high heat, then add the coconut oil. When the oil is melted, add onions, stir with a wooden spoon and cook until they’re translucent, about 7 minutes. Add the garlic and as soon as it’s fragrant, about 30 seconds, crumble the ground meat into the pan with your hands, mixing with the wooden spoon to combine. Continue to cook the meat, stirring often, until it’s no longer pink.
In a small bowl, crush the oregano between your palms to release its flavor, then add the chili powder, cumin, espresso seasoning, turmeric, cocoa, allspice, and salt. Combine with a fork, then add to the pot, stirring like you mean it. Add tomato paste and stir until combined, about 2 minutes.
Add the tomatoes with their juice, beef broth, and water to the pot. Stir well. Bring to a boil, then reduce the heat so the chili enjoys a gentle simmer. Simmer uncovered for at least two hours. Do not skimp on the simmer! Serve in deep bowls, add onions and avocado and sprinkle with espresso seasoning.
For a bit of crunch, add some sweet potato chips!
I have a love-hate relationship with Manhattan. I blame this, in part, on the fact that everyone (myself included) is always busy. This means my medicine must be capable of coming with me on the go!
I spend more money on convenience--sending my laundry out, Uber and food delivery--than anything else. This means that I can't be bothered to take 87 pills twice a day without a system that allows me to manage Lyme on the go or in a rush.
In the past, I used a large weekly pill box that distinguished between AM and PM. But, every time I threw it in my purse the little lids would pop open and spill my medicine every where. The box was also inconvenient when I had to take medicine away from the house and made planning my medicines for more than a week at a time impossible.
One day at Walgreens I ran across little plastic pill bags--they are genius! I label the day and whether they are for AM and PM. I usually make two weeks worth of bags at a time and keep them in a little box.
They are so convenient when I need to take them to a dinner at a restaurant or when I am rushing to work because I can easily toss them in my purse or coat jacket. In addition, they are great for traveling and for planning ahead of time! Finally, they are much less burdensome when I spend the night at someone else's house because I can just take two days worth as opposed to the whole week!
Have any interesting tips of your own? I'd love to hear them!
Mepron--lovingly referred to as "liquid gold" (due to its color and high cost)--is a drug widely used for Malaria. One of its lesser known uses, however, is to treat Babesia.
Although the bright yellow medicine looks intimidating, it doesn't taste nearly as bad as I imagined. A small win, but a win nonetheless!
Mepron should always be a "side dish" to a fatty meal: think eggs, peanut butter, etc. Trust me, you don't want to skip a meal and take this medicine! You will be in for a world of stomach pain.
Because I have to take Mepron twice a day, it means that I have to find a way to take it at work, on the run and on vacation. But, Mepron comes in a large bottle and carries a hefty price tag if you ever lose it or spill it and need to replace it. I knew I needed to find a way to make Mepron more travel-friendly!
My solution was to pour some of the Mepron in a clean glass jar. With my new jar I no longer have to carry the entire bottle of Mepron at once and allows me to leave some at work so that I do not have to carry it back and forth. As an unintended benefit, the large mouth allowed me to more easily get the medicine out of the jar with an oral medication syringe.
Finally, I added a pretty label to make taking my daily dose of liquid gold just the tiniest bit less depressing! I purchased the jar from Fish Eddies in NYC and the syringe from Walgreens.
If you have other helpful hints about Mepron, let me know!