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Top 5 Mistakes You Can Make During Open Enrollment

Now that summer is ending and school is beginning, it won’t be long before the busy open enrollment season is upon us. While most of us don’t look forward to wading through benefits descriptions, it’s important to put those feelings aside and invest some thought in the process. Taking time to study your options now could not only save you money, but also affect your health care choices for the coming year.

5 Mistakes to Avoid when Choosing Your Health Coverage.

  1. Buying on price alone. Finding affordable insurance is getting harder and harder, but buying on price alone is often a mistake. Your monthly premium may be low, but can you really afford that high a deductible? Buying a high deductible plan under the assumption that you are healthy and never need to use doctors is risky. Are you prepared to pay the deductible if the need arises? Can you afford the cost shares that may kick in after the deductible is met? If your employer offers worksheets or modelers for comparing the available plans, take advantage of them and do the math.
  2. Not considering your family’s situation. Of course, you can’t predict everything that might happen, but you can look at your current health status. If someone in your family has a medical condition, you can take their care plan – upcoming tests, specialist visits, and medications – into account. You will also want to look at your values and attitudes. If you like to be in charge of your care, you might be willing to pay extra for a plan that doesn’t require referrals to specialists.
  3. Not verifying your providers’ participation status with your health plan. Providers who are considered in plan have a contract. Contracts change and it is not unusual to have providers cancel participation with a health plan. Just because your provider was “in network” and “participating” last year doesn’t necessarily make it so this year. Call the health plan and call your doc to verify. Check your health plan’s website for an up-to-date list of participating providers.
  4. Renewing into the same benefit plan design. Benefit plans change each year. There may be new plan limits and exclusions. Don’t assume nothing has changed. Pay particular attention to your prescription benefit. Drugs lists often change at the time of open enrollment – impacting the tier that drug is on and how much you will pay out of pocket next time you renew your prescription.
  5. Not taking advantage of opportunities to offset cost sharing, if offered. A Flexible Spending Account lets you to put aside pre-tax dollars to use for eligible medical expenses. If you can predict some of your deductible and copayment expenses for the coming year (based on your health needs and the plan design you choose) and put them in an FSA, you can save around 25% on your out-of-pocket expenses by paying with pre-tax dollars.

Perhaps the most important thing you can do is to ask questions. If you don’t understand a benefit offering, ask your Human Resources department. If you’re not sure how much you spent this year, see if you can download your claim history from your health plan’s web site or request a report. Make an informed decision this fall, so you can use your plan with confidence in 2012.

Continuing last week’s discussion, Choosing the Right Health Plan, let’s look at how the actual Benefit Design can — and should — shape your purchasing decision.

When we say benefit design, we’re simply acknowledging that medical insurance plans come in various shapes and sizes; you need to pick one that fits you and your family.

What’s in a Name?

Everything. The name itself often represents the type of product, reflects plan rules or highlights a unique element. Example: HDHP stands for “high deductible health plan!”

HMO, PCP, Gatekeeper — these names are associated with benefit designs from health plans versus insurance companies. They generally require a referral from a primary care physician before you see a specialist. Does that work for you? Are you willing to engage with a primary care physician as part of your health care team? Open Access, on the other hand, typically means you don’t need a referral from a primary care physician to see a specialist.

Points of Service

Before purchasing a health plan, make sure you understand how it’s designed in terms of service. For instance, will you be covered — to some degree, at least — if you see a non-participating doctor?

Warning: if you call a doctor’s office to see if they participate with your insurance and you get this response, “We accept all insurance” DO NOT think it means they participate with your plan. It simply means they’re willing to accept a check from anyone. Ask more questions.

Need physical therapy? Want to see a chiropractor? Make sure these services are covered and if there are limits on visits. It’s not unusual to see benefit designs with limited coverage for these services.

There’s a lot to consider when choosing a heath plan. And the wrong decision can be costly. Check with your state’s Department of Insurance website for a list of all licensed insurance companies and health plans doing business in your state. See what’s available. And when in doubt, consult an expert for advice.

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With the recently passed health care reform legislation, millions of Americans will find themselves having to “purchase” health care coverage. Whether you’re getting coverage for the first time, evaluating Medicare options, shopping for individual insurance, or choosing a plan from options offered by your employer, the process can be complicated and confusing. Start by evaluating the following:

Your Budget

Even if you qualify for a subsidy, determine how much you can pay for health care on an annual basis. Questions to ask yourself:

  • Who will be on the plan? Just you? You and a spouse? What about children? The new bill allows for adult children up to age 26 to stay on a parent’s plan. This decision affects premium rates.
  • Which works better for you: a lower monthly premium with an upfront deductible or a higher premium with no upfront deductible?
  • What about co-pays? If you go to the doctor frequently, you might want a plan with lower co-pays, a higher monthly premium and little, to no, upfront deductible.
  • Think in terms of surgery and preventative care (physicals, colonoscopy, etc). Check the plan for out-of-pocket (meaning your dollars) costs for these services. Many benefit plans include preventative services. Explore this carefully as it could have significant impact when you need care.

The Network
Once you’ve determined budget issues, consider the network. Make a list of all the doctors and health care providers you and your covered family members have seen in the last 12 months. If you currently have coverage, register for and use the plan’s website to review your claims history. Using this information, assess your needs by answering these questions:

  • Do see certain primary care or specialty doctors on a regular basis?
  • Do you prefer a particular hospital?
  • Do you want to be able to obtain second opinions outside of your local area? If so, you might want a health plan that includes some level of coverage for non participating doctors.

When evaluating your needs, be sure to include health care professionals such as physical therapists, chiropractors or optometrists.

Next week Health Champion will explain how to evaluate benefit designs. If you have any questions — or issues you’d like covered — please leave a comment and we’ll address your concerns in an upcoming blog.

Do you carry your own health insurance policy?

Is it time to renew?

If so, don’t do it blindly. And don’t take anything for granted.

Before signing on the dotted line or sending in that premium, you need to know what, if any, policy changes will take place in the coming year. Specifically, check for the following:

  • Provider networks & physicians: have hospitals been removed from the list of participating facilities; is your doctor still in the network?
  • Co-pays: will you have higher coinsurance or deductibles?
  • Benefits: check for benefits that are important to you, whether it’s mental health coverage, physical therapy or visits to specialists. What’s changed? Can you live with the changes?
  • Pharmacy Benefits:  what drugs have been added or changed tiers? Will you be paying more for your meds?
  • Lifetime maximums: If you’ve been in the plan for awhile, are you hitting up against lifetime maximums? Often your expenses against lifetime maximums are not easily discerned from the Explanation of Benefits you receive when a claim is paid. Find out how much you have used and what’s left for specific services. Better to know upfront than find out too late you’ve had treatments that are no longer covered.

Buyer be aware. You may be glad just to have the coverage and assume that year after year changes will be minimal. Caveat Emptor – that isn’t always the case.

And if you’re having trouble figuring out your coverage, call your plan’s representative; be persistent or turn to a specialist who can help you understand your benefits.

“Why won’t my insurance cover a CT Scan of my heart that the doctor says I need.”

That was the call we received recently from a woman who was confused, upset, and uncertain about getting the care she needed.  She’d had questionable results from both her stress test and her cardiologist recommended that she follow up with a CT scan ( to be exact, her doc wanted a CT scan of her coronary arteries, affectionately known as code 0146T).

But her insurance company refused to authorize this critical test.

Why?  Was there anything we could do to help?

We went right to work and here’s what we discovered:

  • The cardiologist’s office followed protocol by calling the woman’s health plan and submitting the required information. However, what was submitted didn’t meet her insurance guidelines.
  • We obtained a copy of the company’s guidelines for radiology, and then compared the information sent by the doctor.
  • We then interviewed the woman and discovered she’d neglected to mention certain symptoms to her doctor.
  • We discussed those symptoms with the doctor’s office; they updated the information, sent it off for insurance review, and the test was authorized.

Lessons learned…

  • Always ask why. If you need a test/procedure and your health plan won’t authorize it, ask for clarification. You’re entitled to a copy of the guidelines used to make the decision.
  • Don’t assume that your doctor’s office will engage with the health plan on your behalf. Stay on top of the situation.
  • Review the information and symptoms you’ve shared with your doctor and see if there’s more that might be helpful.
  • If you’re having trouble getting answers, enlist help. Don’t just settle for “no.”
  • Realize that by enlisting a private advocate, you save time and money and get results.