Financial Counseling

Financial Assistance

Be Proactive

• Covered services
• Co-payments for specialty visits
• Yearly deductible and out of pocket. Are they met?
• Do co-pays apply to other services other than office visits (CT scans injections/labs/chemotherapy)?
• Do I need a referral for outside labs, diagnostic procedures, and CT/X-ray testing?
• Are the oncologists at Charleston Oncology in my network of coverage?
• COBRA coverage
• Job loss resulting in loss of insurance – we provide options
• Other health insurance updates/questionnaires
• Do I qualify for Medicare/will I be penalized if I don’t get Medicare by my current plan?
• Change of insurance

Pre-certification, Pre-authorization & Referrals

Insurances

• First Choice/Select Health
• Humana
• Molina
• Multiplan
• Railroad Medicare
• South Carolina State Health Plan
• Traditional Medicaid
• Traditional Medicare
• Tricare Standard and Prime
• United Healthcare
• Wellcare of South Carolina

Question & answers

Common Insurance Terminology

• Co-Payment: The co-payment is a fixed payment made by the policyholder at the time of service, as required by the insurance provider. Co-pays vary but the policyholder can expect to pay more for specialty visits as well as emergency room visits.
• Deductible: The deductible is the total amount that a policyholder must pay in order for their medical coverage to begin. Deductibles are usually reliant on the premiums (or monthly payments). For example, if the policyholder has smaller monthly premiums, then they can expect a larger yearly deductible. This is compared to someone paying higher monthly premiums with a lower yearly deductible. The employer may also set the deductible and out of pocket.
• Coinsurance: Coinsurance is the percentage of costs the insured is responsible for paying once the deductible has been met. For instance, an individual with a $500 deductible and 20% coinsurance would pay for the first $500 of medical care costs, and then would pay 20% of subsequent costs until reaching the out-of-pocket maximum for that policy. The insurance company pays 80%. Once the policyholder reaches their out-of-pocket limit, the insurance company pays 100%.
• Out-of-Pocket Limit: The Out-of-Pocket Limit (also known as Out-Of-Pocket Maximum) is the maximum amount of money the insured may pay for medical services in a calendar year. The out-of-pocket limit may or may not include the deductible depending on insurers’ definition of the term. The maximum amount of money the insured may spend for health care services also may vary whether they are received in or out-of-network. The out-of-pocket may or may not be based on a calendar year.
• PPO Insurance (Preferred Provider Organization): A healthcare organization that teams with a collective group of healthcare professionals including physicians, laboratories, and hospitals to provide a reduced cost of care to policyholders who pay a monthly, quarterly, or yearly fee. In general, most PPO policyholders are assigned a primary physician that is able to provide patients with referrals for specialists in their covered network. In most instances, there are deductibles and co-payments that policyholders are responsible for.
• HMO (Health Maintenance Organization): A healthcare organization that requires a flat monthly rate, not bound by deductibles, but policyholders are limited to care only within their network (meaning you can only receive treatment from healthcare professionals in your network)

Medicare Advantage Plans (MAs) and Medicare Advantage Plans with Prescription Drug Coverage (MA-PDs)

Medicare Advantage Plans are health plans that are approved by Medicare and provided by private companies such as Aetna, Cigna, Coventry, Health Net, Humana, United HealthCare, WellCare, and many others. Medicare sets the rules for Medicare Advantage Plans and regulates the private companies who operate the Plans.

Medicare Advantage Plans are also sometimes referred to as Medicare Health Plans, Medicare Part C Plans, MAs/MA-PDs, and PFFS (and originally, Medicare Advantage Plans were called Medicare+Choice plans). A Medicare Advantage Plan combines your Medicare Hospitalization (or Medicare Part A) and Medical insurance or Doctor’s Visit Coverage (or Medicare Part B) into one Health Plan that provides the same medically necessary services as original Medicare. Some, but not all Medicare Advantage Plans also offer Prescription Drug Coverage (or Medicare Part A and Medicare Part B and Medicare Part D) at no additional cost.

Can anyone join a Medicare Advantage Plan?

No. A person must meet a few conditions to be eligible for a Medicare Advantage Plan. If you wish to enroll in a Medicare Advantage Plan (a MA or MA-PD), you must be: eligible for Medicare, enrolled in both Medicare Part A and Medicare Part B (you can check this by referring to your Red, White, and Blue Medicare Card), live within the Plan’s service area (which is county-by-county – not state-by-state), and not have End-Stage Renal Disease (or ERD). For example, if you and a friend both have Medicare Part A and Part B, but live in different counties, your friend may be able to join a Medicare Advantage Plan that has a prescription drug benefit (MA-PD) with a $0 monthly premium. However, this same MAPD may not be available in your county a few miles away.

Do you lose your Original Medicare Part A and Part B when you enroll in Medicare Advantage Plan?

No. Once enrolled in a Medicare Advantage Plan, the private company offering your Plan will take over some of the administrative processes to implement your Medicare benefits; however, you do not lose your Original Medicare. Later, if you wish to leave a Medicare Advantage plan, you can return to your Original Medicare Part A and Part B coverage during either the Annual Coordinated Election Period (AEP) or the Open Enrollment Period (OEP).