Buying health insurance can be intimidating. And with the debut of state health insurance exchanges, it can be confusing trying to figure out the type of plan that you should buy. So how do you know what plan to purchase? Plus, if you’ve got a plan, how do you know if it’s a good one? Nancy Metcalf, senior writer at Consumer Reports Health, helps us answer these questions.
Conveniently, the new health care law defines what everything is. It’s written into the law. It’s called essential health benefits. They’re what you think they would be: hospitalization, doctor visits, outpatient treatments, drugs, tests, preventive care like immunizations and mammograms, pediatric care, mental health and substance abuse care, rehabilitation,” says Metcalf.
One thing that isn’t always included in a plan is maternity care. Metcalf says right now in most states, if you buy insurance on the individual market — as opposed to getting it through a job — it’s nearly impossible to get maternity coverage. But she says that health benefit will now be included in pretty much every insurance plan that starts after January 1, 2014.
Metcalf says insurance companies have become good at hiding what’s in their plans, though that has changed recently.
What should you do if you want to know what’s in your plan?
Since last year, every insurance plan — whether you get it on your own or through a job — has come with a standardized form called the Summary of Benefits and Coverage. It looks the same for every plan and it goes through all the details of what’s in the plan and how much you have to pay for it. What’s the deductible, what do you have to pay to go to the doctor,” says Metcalf. “If things aren’t covered, it will say so. If you have any doubt of what’s in your plan, go to your HR department or call the insurance company that sold it to you and say ‘I want to see the summary of benefits and coverage.'”
If you get health care through your job, Metcalf says your employer should have that document available to you or can get it from the insurance company.
What is the Affordable Care Act going to do?
“Buying insurance on your own is about to become a completely different and vastly improved experience over what it is today,” says Metcalf.
Metcalf says most of the insurance that you get through a job is probably going to be good, especially if you work for a large employer. But where most people run into trouble is buying insurance on their own — something that’s about to change because of the Affordable Care Act.
Everybody who buys insurance on their own should look at their state’s insurance exchange market, which debuts Oct. 1, says Metcalf. If you have a plan now and keep it, that fulfills your requirement to have coverage. However, you can’t get financial subsidies to buy health insurance unless you buy it on your state’s marketplace. Metcalf says most of the people who are buying on individual market are eligible for some kind of subsidy.
What should you consider when you’re purchasing insurance on the state insurance exchange market?
“If you go onto your state’s marketplace, one of the things that you can be sure of is that every single plan sold on that marketplace is going to cover everything, so that’s one thing that you don’t have to worry about,” says Metcalf. “But even so, you’re going to have some choices. The main choice is whether you want to pay more upfront for your insurance and less when you use it, or the other way around.”
Metcalf says the insurance will be sold in metal tiers — bronze, silver, and gold.
“Bronze plans will be quite inexpensive, but when you use them you’ll be paying more out of pocket. You’ll be paying higher deductibles, higher co-pays. Silver, kind of in the middle. Gold will have the highest premiums, but the lowest deductibles, co-pays,” says Metcalf.
Metcalf says there are two things to consider when purchasing insurance on the exchanges.
First, what it covers. Insurance is for stuff you don’t know is going to happen, says Metcalf. You may not take prescription drugs right now, but you could need it in the future, so it should be covered. Second, how are you going to pay for it? There are two pieces to paying for it. First, paying upfront. We’re talking about the premium, which is the monthly fee that is paid to an insurance company or health plan to provide health coverage, including paying for services such as doctor visits and medications. Second, paying when you access the services, the co-pay. Metcalf says most people would like a cheap plan with no co-pays, but there’s not a better or worse way to pay.
If you’re usually healthy and have a little money set aside in bank, you can get away with a higher deductible plan with a lower premium, Metcalf says. Odds are you aren’t going to need a lot of health care. If you do have to go to the doctor, you’ll pay out of pocket. If you are someone with an ongoing medical problem — for instance, someone with asthma who has to buy expensive inhalers or a diabetic you’ll know what you spend on your medications and can look at health care choices with that in mind. For people with chronic conditions, it might make more sense to pay more upfront and less for when you access services.
One last thing to consider is who the providers in the plan are.
These are all private managed care plans — PPOs, HMOs. They all have provider networks. It’s really important, if you have a doctor or a hospital or facility that you have a relationship with, you’re probably going to want to pick a plan that includes that provider. When you go on the marketplace, one of the things you’ll be able to see is a provider directory so you can look it up for yourself,” says Metcalf.
What about people who get insurance through their jobs?
If you work at a big company, you might have a choice of a few different plans. Metcalf says you need to go through the same decision-making process that you would if you were purchasing insurance on the market. You should look at the networks, look at the cost- sharing (what patients pay for a portion of health care costs not covered by insurance) and decide which plan is best for you.
Have you ever wanted to try a certain medication or treatment, only to discover that it wouldn’t be covered by insurance? That’s because insurers follow a practice of step therapy to help control costs.Â
Step therapy, also known as “fail first,” requires a person to “fail” on one or more drug approved by the U.S. Food and Drug Administration (FDA) before the insurer will cover another medication that may be preferred by the person or their health care provider. Some insurers also require that a person tries and fails on one or more prescription medications not approved by the FDA for the condition being treated, a practice known as “forced off-label prescribing.”A
Off-label prescribing occurs when a physician prescribes a drug that is FDA-approved for a use other than the condition for which it is being prescribed. For example, medicines approved to treat depression may be used to treat chronic pain.
The practice is legal and commonly practiced. In fact, one out of five prescriptions is written for off-label use, according to the Agency for Healthcare Research and Quality. Some, understandably, argue that step therapy and, particularly, forced off-label prescribing transfers decision-making from health care professionals to insurers.
Here is an example of how a typical forced off-label prescription scenario could play out.
Condition: Moderate to severe hot flashes
Desired medication: Newly FDA-approved, nonhormonal prescription medication called Brisdelle.
Forced off-label process: The only other approved treatment for hot flashes is hormone therapy, which some women are unable or unwilling to use. Insurance will require women to try and fail on non-approved FDA medications before trying Brisdelle, which restricts their options and may delay their relief.Â
What can you do? If you are concerned about being forced to try medications that are not FDA-approved for treating hot flashes (or other conditions) or you want to help ensure prompt access to medications that are FDA-approved, contact your insurer, legislators, state insurance commission and state attorney general’s office to let them know that forced off-label prescribing is not acceptable and may not be in the best interest of your health.
There is hope. Three states Maryland, New Hampshire and Vermont recently passed laws restricting forced off-label prescribing to protect patients and return decision-making to the health care providers.
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