Tuesday, December 1, 2015

The Successful Patient: Medical Insurance



It's that time of year, folks! Whether you're in open enrollment for Medicare or shopping for a new private plan through an ACA online marketplace, you are the target of the medical insurance industry's attention.  They want you!  Especially if you're between the ages of 21 and 49, healthy, and willing to pay.

Last year, I wrote about my trials with MNSure, Minnesota's online marketplace through the ACA.  This year, I thought I wouldn't need to shop for another plan.  The plan I'd bought at the end of January this year, effective February 1, was just what I needed and had been a lifesaver this year.  However, the company claimed that they'd lost a lot of money this year because of patients with chronic illnesses on individual plans and large claims, and so they raised their premium rates by 50% in order to cover those costs in the coming year.  I received a "renewal information" letter from them in which they informed me that my premium would be $1000 per month and they would no longer participate in MNSure, so my plan was no longer eligible for premium tax credits. What?! Can they do that?! Turns out they can.


A second very large insurance company in Minnesota recently announced that they were reviewing their participation in the ACA and were thinking of pulling out because they were losing so much money.  I'm still trying to figure out how these companies could be losing money.  By law, any "profit" they make -- most are non-profit companies -- must go into a fund to cover any unexpected costs from high claims in any given year.  At least one of these insurance companies has a fund with hundreds of millions of dollars in it.  Let me put that in numbers: $100s of millions.  For my plan's company, the estimate was about $500,000,000.  How these companies are losing money is beyond me, unless they are not using the money in these funds to cover those unexpected costs.

So what do you need to know when shopping for medical insurance through an ACA online exchange?

First, insurers are not  your friends!  They do not have your best interests in mind, except when it benefits their bottom lines.  You will not receive any sympathy from them if they deny coverage of something.  Prepare to fight for what you need, if necessary.

Second, make a list of your doctors, clinics, hospitals and pharmacies that you need, i.e. those medical providers that you are using and happy with.  Check this list against an prospective insurer's in network providers.  I always make certain that all my providers are on that important list.

Third, make a list of your medications.  Check this list against the prospective insurer's formulary, i.e. their list of covered medications.  Most insurers also have a non-formulary list and a specialty drug list.  Check your meds against these lists too.  I want all my medications to be covered so they need to be on an insurer's formulary list.

Fourth, decide what you can pay for a monthly premium, for deductible, and for out-of-pocket expenses (for co-pays/coinsurance).  These three costs are your costs on the plan.  For example, say you have a monthly premium of $100 (I know, wishful thinking) X 12 months = $1200.00 annual premium cost.  Add to that your deductible of $3000, and your out-of-pocket costs of $5000, and your total costs for the year will be $9200.00.  That's what you'll be paying.  If you are shopping on an ACA marketplace, the plans will have a metal assigned to them according to the percentage the insurer pays.  For example, platinum = 90% paid by insurer (your coinsurance will be 10%).  Gold = 80%, Silver = 70%, and Bronze = 60%.


Fifth, do you travel a lot?  You may want to consider buying a plan from a national insurer rather than a regional or state insurer in order to get coverage nationally.  Blue Cross Blue Shield is an example of a national insurer.

Sixth, consider getting help with your application.  The smartest thing I did this year was to work with an assister called a Navigator who talked with me about my first five points above, then filled out the application for me.  An error message came up immediately as she began, a message I encountered last year and took many days to correct.  The Navigator took care of it with one phone call.  She made a photocopy of my application for my file and submitted the application for me.  I can call her for help and guidance if any issues come up during the next year regarding my application or MNSure.

Seventh, prepare to continue to do a lot of work with your insurer, especially if you have one or more chronic illnesses.  Most insurers have wellness plans in which they will want you to enroll.  In this way, they can keep an eye on your health more closely than if you weren't in the plan and talking with their RNs quarterly or monthly.  I've vacillated about the effectiveness of these programs.  I find that for my situation, I am in almost constant contact with my medical team and do not need an insurer's team of RNs running interference for me in any way whether it's to advise me what to say or what to do with my medical team.  However, for some people, a wellness program could provide support and needed education.

And finally, insurers are not your friends!  They are in a specific business and their business is to make money (yes, even non-profits want to make money, not just break even).  They love people who will pay them more than they have to pay out on them in claims.  Remember that they are business people and treat them as such and you will be more successful in dealing with them.  Your medical providers can also be of invaluable help, especially if you need prior authorization for any medication or procedure.


I remember that when I was in college, I was on my father's medical insurance policy as a dependent.  Then, after college, when I started my work in the adult workplace, I was on an employer's business policy for medical insurance.  When I left fulltime work, I bought an individual plan for medical coverage and paid my premiums every month on time.  I was healthy and never filed a claim.  Then, with age came more health issues and suddenly I was up to my ears in dealing with insurance companies and I hadn't a clue what I was doing.  It never occurred to me to educate myself earlier. 

Please don't make that same mistake.  Educate yourself on what's available in your area, and take the time to make the lists I suggested above.  It will save you a lot of time and aggravation in the long term.


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