February 25, 2021
At a recent visit to your doctor’s office, it was determined you may benefit from a certain type of home medical equipment (i.e. a breast pump, nebulizer, blood pressure monitor, etc.); so your physician faxed us a prescription and either provided the product directly to you, or we shipped to you! Your doctor may have explained that your insurance “covers” this product.
Weeks later, you receive an explanation of benefits (“EOB”) from your insurance. Shortly thereafter, you receive a bill from Acelleron and you may be asking yourself:
- Who is Acelleron?
- What are these charges for?
- I thought my insurance was billed for this equipment?
- Why isn’t the equipment “covered” by my insurance?
Do not worry! These are common questions when it comes to a commercial/private health insurance plan, and thus we want to educate you. Before we get started, here are some key terms you should understand:
- Deductible – the amount of money the member/family must pay out-of-pocket each year before your insurance begins to pay.
- Co-insurance – the percentage of health service cost the member/family must pay after your deductible has been met (i.e. 80%/20% means your insurance pays 80% and the member pays 20% of the product or service).
- Co-pay – the amount due at the time of your service, per office visit.
- Out-of-Pocket Maximum – The maximum amount of medical expenses the member/family will have to pay each year before your insurance will cover remaining expenses for that plan year.
To calculate how close you are to reaching your out-of-pocket maximum, you would add your deductible, co-insurance payments, co-payments and then subtract that from your plan’s designated out-of-pocket maximum. Once you reach the maximum, your insurance should cover all costs.
These key components to your insurance are typically found on the front or back of your insurance card and will help you understand why you are receiving a bill from Acelleron. And by the way, who is Acelleron? That’s easy! Acelleron was the home medical equipment provider your physician sent your order/prescription to. Physicians will typically refer their patients to home medical providers that provide high quality products and services that meet their patient’s needs.
What does “covered” mean?
And, what about your question about the equipment being “covered” by your insurance? Due to the rise of deductible insurance plans there has been increased confusion about what is a “covered” product or service. The truth is, “covered” now means your insurance recognizes and will pay for that product or service code, however if your plan has a deductible or co-insurance, you will be responsible for meeting those thresholds before your insurance picks up the tab.
If you have further questions about your insurance plan, we always recommend you call your insurance member services hotline as they can help you understand the key components to your specific insurance plan. The member services phone number should be on the front or back of your insurance card.
And while you are on the phone with member services, do not hesitate to ask a few more critical questions that will help you make better decisions when it comes using your insurance. Below are some other questions you may want to ask:
- When can I get new equipment?
Your specific plan may have restrictions on how often you can receive (or replace) this equipment. For example, most insurance plans cover one breast pump per pregnancy/birth. Yet, there are a few that have more restrictions, such as one breast pump every two or three years. If your insurance is the same as when you last received this equipment and the equipment no longer works, check the warranty, and if under warranty, call the manufacturer to have the device repaired or replaced.
- Are accessories or replacement parts covered by my insurance?
Depending on your insurance and the specific accessory or replacement part, it may or may not be covered. Your insurance can explain if and how often these parts can be replaced so that they are covered through your insurance. For example, most health insurance plans in the northeast do not have sufficient coverage for breast pump replacement parts. If they are not covered, we suggest purchasing these products online. However, a nebulizer cup and tubing kit is typically covered one every six months.
- Are breast pumps free through my insurance?
Usually, but there are exceptions. Under the Affordable Care Act (“ACA”), health insurance companies must cover a breast pump with no out-of-pocket costs. While most plans follow the ACA and will allow one (1) breast pump per pregnancy, there are instances where the ACA is not followed (specifically grandfathered plans and individuals under age 26 covered under a parent plan.) Knowing your plan guidelines for receiving/accepting a breast pump is important.
Written by Cheryl Fillmore, Director of Revenue Cycle at Acelleron.