Health Insurance Q & A | TN

There are five important things you need to consider when comparing health insurance policies.  

Health reform and the ACA mandate that plans must meet certain requirements under the health care reform law: Pre-existing conditions can no longer be excluded. In addition all plans must cover the 10 essential health benefits and most preventive services are covered at no additional cost to the insured. While each insurance company must cover the EHBs, they don't have to cover them in exactly the same way. When you compare one Silver Plan to other Silver Plans, you may see they differ greatly. As you begin to shop for an individual or family health plan, there are five questions you need to consider. By taking the time to do this homework you should be confident in the policy you choose. 

1. Can I continue to use my current doctor and hospital?

One of the ways insurance companies are keeping premiums down is by creating a new type of doctor network. In the past you could choose from nearly all providers in your area, and then insurance companies created "narrow networks where one of the main hospital chains may not be included (S network from BCBST). This generally left you with most of the hospitals and most of the doctors to choose from. Today we have "skinny networks (E network from BCBST) that generally consist of one main hospital network and their doctors. While this is not a bad thing, it is very important that you understand who you can see and who you can't. If your long-time family doctor is not in the network, you won't be able to see him and have the insurance pay for it. More importantly is your local hospital or the one you would prefer if you were going to have a big procedure included.  Back to top

2. Do I have to ask permission to see specific doctors (Gatekeeper)?

Another very important part of the provider discussion is how you access different doctors and facilities. There are two types of plans, open access and gatekeeper and they work like they sound. Generally when two health plans that look similar have very different costs it's because one has a "gatekeeper type plan. What that means is that your PCP (primary care doctor) is responsible for coordinating all of your healthcare needs. He understands your history, the medicines you take and what you are doing to control any illnesses.  When you want to see an cardiologist or another type of specialist, you have to see the PCP and get their approval before you move to the next level of care. This is a great way to control unnecessary costs but if you are not used to it you may not be happy with a plan like this. These plans are generally called HMO (health maintenance organizations), EPO (exclusive provider organizations) and now there are ACO (accountable care organizations) plans. We think the new E network from BCBST will be an ACO and may require PCP authorization. 

The other option is "open access where it works like it sounds; you can see any provider as long as they are in your "doctor network without asking permission. That does not mean they can just do any procedure they want, that must still be approved by the insurance company but you have much more flexibility. These plans are generally called PPO (preferred provider organizations) or POS (point of service) plans. Back to top

3. How much will I pay for my prescriptions?

This can be the most expensive mistake you can make when choosing a plan if your prescriptions are not in the right "formulary (a list of prescriptions and the level of payment for a 30 day supply). Many people take prescriptions day after day, year after year and they can be very expensive. Before you meet with your insurance representative (agent/broker/navigator/assister) you need to write down each prescription and the dosage. 

As you are looking at different health plans pay careful attention to the prescription column, there are many ways prescription benefits are structured. The least expensive plans will cover prescriptions subject to your deductible and co-insurance or have a separate deductible. That means you pay the full cost of the medicine until you have met your deductible, then you pay the co-insurance amount until you have met your maximum out of pocket. 

Some plans will have co-pays, let's say the plan has a 5/35/60 Rx card. That means generics cost $5 for a 30 day supply, "preferred brand names cost $35 and "non-preferred brand names cost $60. Makes sense right, now hears the tricky part, each insurance company and many times the plans themselves use different lists for where the prescriptions fall in the co-pays. If you take Nexium for instance, its average cost is around $160 for 30 days. That is what you would pay with a "deductible plan. With a co-pay plan, you need to know if it's considered preferred or non-preferred before making your decision. Make sure you see the drug formulary before making your final decision. 

Are you paying too much for your prescriptions? What are your options? Learn more with this Rx cost calculator from AARP and Consumer Reports.  Back to top

4. What types of claims do you expect to have next year? How much is the Out of Pocket Maximum?

Consider how you use healthcare during the year or what might be coming up in the next year. While this is never a perfect science, history is a good indicator and should help you answer this question.  If you have a condition that requires you to have quarterly checkups, you know you will have those four visits next year. Do you have a planned surgery or maybe are pregnant? Those are big claims and you need to understand how much you will spend if you have a $2,000, $12,000 or even a $75,000 claim. One way to find out how much your office visits cost is to look back at your EOB's (explanation of benefits), these will show the actual "discounted charges.

If you have regular doctor visits it's important to know what the actual charge is. Here's why, you might have a choice of two plans you like, one has doctor visits going toward your deductible, the other option has a $50 co-pay. When you look at the EOB you see the discounted charge is $80 per visit. That means your insurance is only paying $30 of that visit and you are paying the rest. Sometimes you are better off paying the lower premium and paying more when you do see the doctor. 

The next question (if you have more than two people on your policy) is if the deductible is "embedded" or "shared". This little thought about aspect of health insurance gives a nasty surprise if you don't understand how your policy works. An embedded deductible means no one person in the family can pay more than the individual deductilble. A shared deductible generally doubles the individual deductible and everyone covered under the policy "shares" that larger family deductible. As an example, if the plan you are looking as has a $2,500 individual deductible with two per family, with embedded the most you would pay toward your deductible for a large claim is $2,500. However, with a shared deductible, one person can be responsible for the 2x family deductible of $5,000. Back to top

5. How does this plan compare with my group insurance at work?

Employee benefits are a great thing and in many cases will be a better deal for you or your family. That is because it has two big things going for it; the first is the ability to use pre-tax dollars to pay for your part of the premiums. The other is that the company is paying toward the cost of your coverage. That said it still may not be your best option. When you look at the answers to the questions above you need to do the same calculation with your health insurance policy at work. If you know you are going to have high claims this year and the group plan has a $5,000 out of pocket, you might be better off buying an individual policy on the marketplace with a $2,500 out of pocket and paying a little more for it (you don't want to pay an extra $200 per month though). You should also look at the cost of your dependents. Most group plans have one set cost for child or children, if you have just one child it may be much less expensive to get them a single policy on the marketplace, do the same calculation with your spouse especially if you are younger. Remember the tax savings with group insurance but if you can save 20-25% (or more), it makes sense. Because you have group insurance available through your employer you will most likely not be eligible for any premium tax credits so keep that in mind when making your decision.

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