health plan

Open Enrollment: A Critical Time for You and Your Family

Whether you’re one of the lucky folks who still have health insurance from your employer or you purchase insurance on your own, open enrollment is right around the corner. It’s a critical time in terms of choosing or renewing benefits, so approach with care and caution.

Here’s what it is:
An annual event, open enrollment gives you an opportunity to change your current health plan or benefit options, such as dental or vision care. Once open enrollment is over, you can’t make any changes to your plan design for an entire year, unless there’s an IRS qualifying event, such as marriage, divorce birth, adoption, or death.

During Open Enrollment, examine your plan choices for the following:

The Network: Compare your doctors and specialists (along with your preferred hospital) with the plan’s list of network providers. Who’s in? Who’s not? Can you live with that? Are you allowed to use out-of-network providers and hospitals? If so, what are the costs and prerequisites?

Cost Per Visit: Look at monthly charges, deductibles, and co-pay requirements for doctor and specialist visits. Do the math. If you see doctors often, you may want a higher monthly payment with lower co-pay; if you go occasionally, consider a lower payment and higher co-pay.
Prescription Coverage: Basically, you want to compare plans in relation to the annual cost of all your prescriptions. Which plans have a separate prescription deductible? What about co-pays? How much will you save with generics or ordering by mail?
Plan Features & Overall Coverage: Think about the services and supplies you normally use; now imagine the coming year and what you might need. Will you be traveling? Having surgery? Will you need short term rehabilitation and physical therapy? Does your plan require precertification? Are you covered anywhere in the U.S. or if you travel abroad? Are preventative care and immunizations covered? Of the plans you’re considering, which offers discounts for services like gym memberships? Is that important to you?

Choose your plan according to your needs — the ones you have now and the ones you envision for the coming year. You only get one chance each year to get it right. If you need help comparing plans and benefits, give Health Champion a call. We’re here to make Open Enrollment easy on you.

Where’s Common Sense When You Need It?

We’re offering a friendly challenge to the CEO’s of all health plans: leave your corner office and walk a mile in the shoes of people covered by your plan. What do you see? What touches your heart? What are you doing right? And what needs fixing? Notice a common theme in your walkabout: a lack of plain old common sense.

Here’s a case-in-point from an experience with Oxford, as we attempted to help our client through the health care maze. She engaged our services, signed a HIPAA form, as well as a form authorizing Health Champion as her representative. Because many health plans have their own authorization forms (wouldn’t standardization be in everyone’s best interests?), we immediately contacted Oxford. Here’s what ensued in our dealings with customer service:

O: Reading from the computer screen (no thinking necessary!): the completed form must be mailed to Oxford at their Bridgeport, CT address.

HC: Our client needs immediate help. Can we scan the signed form and email it?

O: No.

HC: Can we fax it?

O: No.

HC: If we overnight it, how long before the information becomes available to customer service reps?

O: About a month.

HC: Is there someway to move this along?

O: Nope.

HC: Our client needs help now. Isn’t there something we can do?

O: Well, you could get her on the phone with you, call in together so that she gives permission for the rep to answer your questions.

And you didn’t tell us that upfront?

We did just that. Our list of questions was long and the customer service rep was ill prepared to answer them, frequently placing us on hold to check with someone or something (a manual?). We reached the end of a long business day and our client was fading (remember, she’s dealing with health issues).

HC: Let’s finish this tomorrow. Can you note in the system that we received permission to speak to Oxford; can we continue the call in the morning without having to get our client back on the phone?

O: No.

HC: Why not?

O: We can’t do that. We are only allowed to get verbal approval for one call.

HC: But the call isn’t finished.

O: Sorry we can’t do that. The federal law, HIPAA, prevents us from doing that.

Since when? (When in doubt, quote the federal law, even if you’re wrong!) Now, there’s common sense in play!

CEO’s: are you paying attention? While health and clinical services are critical to accreditation from the National Committee on Quality Assurance, we suggest that, a common sense standard is just as critical.

Your thoughts? Post your experiences, comments and insights.

Read Your Plan Documents

How was I to know that my health plan didn’t cover this?…

With over 25 years each working within the health care system, you can only imagine how many times we at Health Champion have heard this question. Whether receiving a unique or experimental treatment, seeking care from a state-of-the art facility, or simply seeing a doctor who happens to be outside of your health plan’s network, you can easily find yourself in a frustrating and expensive situation if you don’t know what your health plan covers.

Health insurance is a valuable benefit especially in today’s times. Unfortunately, too many people really don’t know much about their plan and don’t seek to learn about their coverage until they are in the midst of a crisis.

Fortunately, there are numerous resources available to health plan members. Health plans go to great length to provide information to their members. Benefit summaries, membership agreements and other coverage documents are typically available in hard copy or on-line. Members can contact their health plan’s customer service line or refer to the plan web site to learn how to access this information.

Health plan members should review their coverage and make certain they understand how their health plan works. And most importantly, Health Champion strongly encourages members to review their health plan before seeking care and whenever they have a question about whether a service is covered.

Prior to seeking treatment ask yourself, “Am I 100% certain these services are covered by my health plan?” If not, reach for your membership documents or call customer service! Many employer plan years begin in January. Now is a great time to review your health coverage!

The Test Gets Authorized

“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.

Health Champion Blog

"In Your Corner"

Open Enrollment: A Critical Time for You and Your Family

Where’s Common Sense When You Need It?

Read Your Plan Documents

The Test Gets Authorized

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