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A Guide to Understanding Your Healthcare Insurance Benefits

This resource was created in 2004. While much of the information on these pages continues to be relevant, some of the systems and policies referred to have changed. PHA is working to revise and update this guide. If you identify areas in need of update or content that you think should be added to this resource, please contact us at insurance@PHAssociation.org

HOW CAN THIS GUIDE HELP YOU?

The Pulmonary Hypertension Association (PHA) has put together this guide to help you understand your health insurance coverage and to provide you with tools to obtain the most from your benefits for all of your healthcare needs.

The PHA's mission is to seek a cure, provide hope, support and education, promote awareness and advocate for the pulmonary hypertension community. We hope that this guide will help you effectively communicate your healthcare concerns with your insurance company.

Now more than ever, individuals need to get involved when using their health insurance benefits. Understanding your health insurance benefits is important in getting your healthcare expenses reimbursed by your insurance company. It is important that you communicate with your health insurance company (and/or your employer benefits administrator) about any difficulties you encounter in getting reimbursed for your prescription and medical care costs.

Throughout this guide we have included some "real life" experiences from patients and their caregivers who provided feedback during the development of this guide. These stories include obstacles that individuals have had to overcome when working with their insurance companies, as well as helpful suggestions for others based on their experiences.

TABLE OF CONTENTS

How Can This Guide Help You? (see left)

Understanding Your Coverage
     ERISA, COBRA, HIPAA, FMLA
      Medicare
         Filing a Medicare Claim
     Social Security Disability
      Medicaid
     Supplemental Security Income
     Private Payers
     Other Types of Payers

Understanding Your Benefits
     What my plan covers
     How to use my medical benefits
     Prescription benefits

Accessing Your Coverage & Benefits
     Prior Authorization
     How to file an insurance claim
     Checking on the status of your claim

The Appeals Process
     Reasons for coverage denials
     Submitting an appeal
     Grievance Process

Tips for Communicating with your Insurance Company

Appendix A: Glossary
Appendix B: Sample Letters
Appendix C: Medicare
Appendix D: Medicaid
Appendix E: Additional Resources

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The information provided on the PHA website is provided for general information only. It is not intended as legal, medical or other professional advice, and should not be relied upon as a substitute for consultations with qualified professionals who are familiar with your individual needs.

Questions about the site? email web@PHAssociation.org

Pulmonary Hypertension Association
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Silver Spring, MD 20910

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