Paying for Care – Health care coverage for Stress

If you’ve paid attention to national news at all lately, you’ve probably heard or read about the call for health-care reform. Many people are experiencing difficulty accessing the care they need, even if they have private insurance from an employer or other source. Nearly across the board, employers are asking workers to contribute more toward their health care, forcing many people to rethink their care, and possibly even put off care that they need. The National Coalition on Health Care, a nonprofit, nonpartisan group of more than 70 organizations working together for better health care for all Americans, reported that employees who are cov­ered by health insurance through their jobs are paying 120 percent more toward copays and deductibles than they were in 2000. The cost to an employer for a single health plan for a family of four averaged $12,700 in 2008. That means that the average health plan costs for a small company with 20 employees would be more than a quarter of a million dollars each year. To offset their costs, employers are asking workers to contribute more and more toward their insurance. The average cost to employees in 2008 was $3,400.

These rapid and significant increases in the cost of health care are squeezing the budgets of employers and individuals, but, hopefully, health-care reform will soon be under way, and services will become more available and equitable. If you are covered by a parent’s insur­ance and can get all the care that you need, consider yourself lucky, because many people do not have that advantage.

Locating and getting access to help for stress-related problems can be particularly challenging, because the problems can be physical, psychological, or both. As you know, exposure to long-term stress can lead to problems ranging from anxiety and depression to colitis, asthma, and sleep disorders. A doctor treating a patient for a stress-related medical problem—migraines, for instance—might recognize that stress is an underlying cause for the condition and recommend that the patient consult with a psychologist or psychiatrist. While your insurance might pay for you to see a doctor about your frequent headaches, it may not provide coverage, or may provide only limited coverage, for psychotherapy.

Another problem is that, while an insurance company normally will cover costs associated with a serious health event, such as a heart attack (which, as you know, can be stress-related), it often is reluctant to cover costs of preventative measures, such as a gym membership, yoga classes, lifestyle assessment, or counseling. It’s ironic that try­ing to find treatment for stress-related disorders can turn out to be so stressful!

Gaining access to mental health care can be especially challenging. Many health-care plans include very limited coverage for counseling or psychotherapy, forcing families to make up the difference between what their insurance covers and the cost of treatment. Psychotherapy fees can cost upward of $75 for a 45-minute session, making the cost prohibitive to many families and individuals.

Hopefully, this situation will improve beginning in January 2010, thanks to a law enacted by former president George W. Bush in 2008. The mental health parity law requires group health plans to provide the same coverage for mental health conditions such as depression, substance abuse, and bipolar disorder as they would for conditions such as heart disease or cancer.

This law won’t benefit everyone, however, as it doesn’t apply to companies with fewer than 50 employees or to people who buy their own insurance. Still, it will benefit some and may help to raise aware­ness of issues associated with mental health and its treatment. Mental health advocates worked hard to get the law put into effect, and it’s considered a victory in the fight to get treatment for mental health on par with that for physical health.

With more than 45 million Americans uninsured, unemployment on the rise, and the number of employer-provided health plans declining, an increasing number of Americans are relying on pub­licly funded care, or simply not getting the care that they should.

Health-care plans for children are available, meaning that no child should be left without care, but the applications can be complicated and too difficult for many people to complete. Experts and groups such as the National Coalition on Health Care are working to figure out how to solve these problems as they anticipate an increasing need for health-care services, particularly in the area of mental heath.

Health maintenance organization, national coalition on health care, private insurance, sleep disorders,

UNDERSTANDING DIFFERENT TYPES OF HEALTH-CARE COVERAGE

If you’re like most teenagers, you probably don’t spend a lot of time thinking about health insurance. It simply isn’t a topic that’s high on your radar. If you find yourself in a situation where you feel you need treatment that your insurance doesn’t cover and your fam­ily can’t afford to pay for it, however, it may suddenly become an important issue. Let’s take a look at the major programs and types of insurances available.

Employment-based health insurance. This is health insurance that an employer provides as a benefit to employees, and some­times, but not always, their families. The insurance may be pro­vided at no cost to employees, although that is becoming increasingly unusual. Most companies require workers to share some of the costs in the form of copays or deductibles, with requirements vary­ing tremendously from company to company. And it’s important to understand that not all companies offer insurance to employees. In Delaware, for instance, 64.2 percent of all companies provide some level of health-insurance overage for employees, according to the Centers for Disease Control and Prevention. In Montana, however, only 40 percent of all companies offer insurance as a benefit to employees. Larger companies are far more likely to provide insur­ance than smaller ones, and coverage may vary tremendously under this broad umbrella of insurance, depending on the type of policy.

Insurance from one company might come in the form of a Health Maintenance Organization (HMO), for instance, which is a type of health-care coverage that offers care from doctors, hospitals, and other providers with whom the organization has contracted for ser­vices. An HMO generally requires approval for many treatments that would automatically be covered with another type of plan, such as a Preferred Provider Organization (PPO) or a Point of Service (POS). HMOs only cover care provided by approved health-care providers who participate in the HMO’s plan and agree to its guidelines and restrictions. PPOs are managed care organizations that use hospitals, doctors, and other providers who agree with an insurer to provide care at lower costs to the insurer’s clients. PPOs generally are more flexible than HMOs, and usually allow you to choose which health­care providers you wish to use. POSs are sort of combinations of HMOs and PPOs. POSs allow you to see any provider you want, but you’ll pay more out of pocket if the provider isn’t part of the insurer’s network.

Privately purchased health insurance. If someone does not have a job or works for a company that doesn’t provide health insur­ance, or is self-employed, he may need to purchase his own insur­ance. Who gets insurance and how much he’ll have to pay for it varies from state to state. Insurance costs much more in some states than in others, because each state has its own regulations regarding insurance costs. Regulations regarding who can get insurance also vary. In most states, for instance, an applicant can be turned down for insurance based on his health status.

Government-provided health-care coverage. People who don’t have jobs that provide health insurance and can’t afford to buy their own may qualify for Medicaid or the State Children’s Health Insurance Program (SCHIP), which covers anyone who qualifies up to age 18. In 2007, 83 million people were covered by government programs, including 23 million children. Still, more than 8 million children remained without health insurance, according to govern­ment statistics.

If your family is a low-income one and doesn’t have any health insurance, you might qualify for government-provided health-care coverage. Medicaid is a federal program, but it’s state-administered, which means that requirements for eligibility vary from state to state. A big problem occurs when a family’s income is too high to qualify for Medicaid, but they don’t have enough money to cover medical expenses. You can learn more about who is eligible for Med­icaid at www.cms. hhs. gov/medicaid/eligibility or www.cms .hhs. gov/whoiseligible .asp. More information about the SCHIP programs is available at www.cms. hhs .gov/schip or www.insurekidsnow .gov. You also can learn more by calling 1-877-KIDS NOW.

If you are 18 or younger and do not have health insurance, you should know that you often have the right to coverage. Children can be covered by Medicaid in some states; in families where parents don’t qualify for Medicaid but can’t afford to buy health insurance, children should be covered by SCHIP.

No matter what type of insurance you have, or how it’s provided, it’s important to read the terms and applications carefully to see what might be covered and what isn’t. Also, try to determine the terms of payment for services. Most doctors will submit a request for payment to your insurance companies, but some plans require that you make the payment to the doctor and then submit a claim the insurance company for reimbursement. If you must wait for reimbursement, be sure to make arrangements for payment with the doctor’s staff.

DIFFERENT TYPES OF MEDICAL CARE FACILITIES

Medical care is provided in different types of facilities, including doctors’ offices, health clinics or community health centers, and hospitals. Doctors in private practices normally expect payment from patients at the time that services are provided, or they bill their patients’ insurers for payment. If the services doctors provide are not covered by insurance, doctors may be, understandably, reluctant to perform them. Since many mental health services are still not covered by insurance, counseling or psychotherapy services can be particularly affected.

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If your family can’t afford to go to a doctor in a private practice because of insurance or financial concerns, there are some options from which you might receive care.

Clinics and community care centers provide treatment for those who can’t afford to pay a private-practice doctor. Some clinics are run by hospitals, while others are sponsored by cities and/or funded largely by the federal government. Often, patients who don’t have insurance are billed on a sliding scale, depending on their income and the size of their families. No one who needs medical care is turned away, even if they have no income or insurance.

Health Resources and Services Administration (HRSA)–funded Community Health Centers are another option for free or reduced-cost health care for people who are uninsured or underinsured. Some of the centers focus on specific populations, such as migrant workers, Native Americans, people who live in public housing, or those who are homeless. The centers offer both primary and preventative care.

The centers vary greatly in their scope and services, but typically are well run and quite successful. Organized by community-based, usually not-for-profit, health organizations and funded by grants from HRSA, there are thousands of these centers throughout the country, both in urban and rural areas that are considered “medically underserved.” That means that there aren’t enough private doctors

and health-care providers in these areas to care for the nearby popu­lation—not necessarily that the areas are poor. Many of these cen­ters, however, are located in low-income areas. Typically, people who work at these Community Health Centers are very dedicated to the health of the local population and do a great job at providing high-quality care, particularly preventive care, even if the health center itself is not luxurious.

If you need to find low-cost or no-cost health care, you or your par­ents can check with the federal bureau of the HRSA, which maintains a nationwide directory of clinics. More information about the HRSA is available on its Web site at www.ask. hrsa .gov/pc. By typing in your state, city, and zip code and the type of facility in which you’re interested, you’ll be given a list of clinics in your neighborhood. Or, go to your city’s Web site or search for clinics in the city or area in which you live. Another great source for locating free and low cost clinics is NeedyMeds .org, which maintains a state-by-state listing of 3,689 facilities.

HRSA also provides a list of Hill Burton–obligated hospitals and other health-care facilities; because in the past these facilities received government grants and loans for construction and modernization, they are required to provide a certain amount of free and low-cost health care. You can find these facilities on the HRSA Web site, or call the Hill-Burton hotline at 1-800-638-0742.

PAYING FOR MEDICATIONS

If your doctor prescribes a medication for a stress-related condition, either physical or psychological, and you can’t afford to buy the medi­cine, you have several options.

You or your parents can ask your doctor for free medication sam­ples. Most doctors are happy to provide samples if they have them. A more long-term solution, though, is to apply for free medications from the pharmaceutical companies that manufacture them.

Most drug companies offer these to patients who can’t afford them through a variety of assistance programs. Your parents may have to fill out some paperwork and provide proof of financial need in order to qualify, and your doctor will usually need to send a note on your behalf.

You can find out more about free drug programs on the Web sites of the pharmaceutical companies that make the drugs you need. If you were diagnosed with depression and your doctor prescribed Zoloft, for instance, you would go the Web site of Pfizer, Inc., which manufactures that drug.

Some Web sites where you can learn more about obtaining reduced rate or free prescription drugs include:

> Partnership for Prescription Assistance: www.pparx .org > NeedyMeds program: www.needymeds .org

> Prescription Drug Assistance Programs: www.phrma .org > RxOutreach: www.rxassist .org

WHAT YOU NEED TO KNOW

> Paying for health care is a problem for an increasing number of Americans who are struggling with rapidly rising costs and, in many cases, declining insurance coverage.

> Even if your family has a good insurance plan, treatment for mental health services are likely not to be covered, or to be minimally covered.

> Health insurance can be provided by an employer, purchased privately, or government run. Plans vary tremendously in what they cover and who is eligible for them.

> If you can’t afford medical treatment from a physician in a pri­vate practice, check to see if there are any free or reduced-fee health clinics or community health centers available in your area.

> You may be eligible for free medications if they are prescribed to you and you can’t afford them.

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