Some Points to Consider When Choosing a Health Insurance Plan

Whether you’re looking over choices through an employer or participating as an individual, there are some basic features to explore. This information came my way through MedChi, the Maryland State Medical Society. It’s brief and well-organized and meant to be shared with our patients, so rather than re-invent the wheel, I’ll just paraphrase the essentials – and add some editorial comment. Although it focuses on Maryland because our Health Exchange goes live today, the points are generally relevant to all. Thanks to Gene Ransom, III, CEO of MedChi, here it is:

The Maryland Health Exchange goes live on November 19, and many employers and patients are making decisions about insurance as the year comes to an end. Marylanders who are satisfied that their current health plan will meet their needs for the coming year do not need to do anything. However, regardless of whether an individual changes health plans or keeps the same coverage, it is important that all Maryland consumers pay close attention to the specific details of their health benefits.

MedChi recommends that all Marylanders do the following five things to make sure they are making the best decisions about health care coverage for their families.

First, consumers should verify their physician’s coverage network. Using doctors who are in-network will save money on health care, and mistakenly seeing an out-of-network provider can leave consumers paying medical bills out of pocket. So, if consumers have switched plans due to a new job or other reasons, they should double check to make sure their family’s current physicians and area hospitals are in the plan’s network. And as an aside, be sure to let the front desk at your doctor’s office know if you have changed insurance BEFORE you see the doctor, so they can inform you if your coverage with that office has changed.

Second, Marylanders should be sure that the medications they need are covered under their renewed or brand new plan, and verify how much of the burden their family will have to shoulder. It is crucial to know not only the costs of prescriptions but also whether the status of those medications has changed. For example, some medications may be moved to a so-called “specialty tier,” which would likely increase patient out-of-pocket costs.

Third, after determining that a plan covers the medication an individual might need, it is still important to check for medication management policies like prior authorization or step therapy. In the name of controlling costs, some Maryland health insurers have placed barriers squarely in the middle of the physician-patient relationship. Prior authorization policies require that doctors get insurer approval before the carrier will agree to cover certain medications or treatment, while step therapy policies require that less expensive options fail before the insurer will cover the preferred treatment. For Maryland patients living with a host of serious, and often painful, conditions including cancer, arthritis or epilepsy, step therapy can mean days, weeks, or months without effective treatment.

Here’s the editorial part — for my office to obtain a ‘prior auth’ on a medication, it is not unusual for my nurses to take 20-30 minutes on various automated phone lines, finally getting to a human, then telling 3 different people the same information about why they’re calling, getting disconnected and having to start all over. We have thousands of patients. Can you imagine doing that for even a small proportion of the medications people are on? Often when we are told we need a prior auth for a medication, the names of the equivalent meds that DON’T need a prior auth are not supplied. Or alternatives that are given are not equivalent. It’s unpredictable from plan to plan which medication will be ‘preferred’ because it depends on the price that plan has paid the manufacturer for the medication. I think it’s important for you to understand the process, because like my office, your doctor’s office might start to refuse to do a prior auth or ask you to speak to your benefits plan about it.

The step therapy policies noted above may take you from a medication that you have tolerated for years and have you try one with many drug interactions and side effects that yours don’t have, because the latter is less expensive for the plan. If I were making money from restricting medication use, I would think these concepts were ingenious. But for your sake, you need to try to avoid them, if possible. Some of the newer medications cost thousands of dollars, so this system is understandable, but some of these routines are over everyday meds. 

Fourth, check copayments and deductibles. Too often Marylanders go to pick up medication and are surprised by the amount they have to pay. In order to estimate the full cost of health care, consumers should determine what co-pays, deductibles and other out-of-pocket expenses they will be responsible for paying – for medications and for doctors visits.

Finally, (I think this is the most difficult part), it is critical to read the fine print. Although consumers frequently accept licensing agreements without fully reading the terms and conditions, the choice of health care is too important to not know what you’re getting. Make sure to read all of the plan materials thoroughly. Doing so will tell consumers what their rights and responsibilities are under each plan, and can prevent consumers from incurring unexpected medical costs later on. If any part of a plan is unclear, Marylanders should contact their human resources department or insurance carrier.

Although selecting the appropriate health care coverage can seem daunting, it is vitally important to the continued health and economic well-being of Maryland families. We urge all consumers to know what they’re getting when they sign up for coverage.

If you’re in the position to select a new health plan, I hope this information will help you organize your thoughts about which one suits you best.  Good luck!