As open enrollment begins, once again, change seems to be the one constant in health insurance. Several insurance companies announced they are leaving several health exchanges in 2017, including Aetna, United Healthcare and Humana. In addition, other smaller insurance companies, like Scott & White Health Plan are also leaving or reducing their participation in exchanges. How do these changes affect you? Well, that depends on your health insurance, healthcare needs, and where you live.
Your Insurance
If you're lucky enough to have insurance provided by your employer, these changes may not greatly affect you. And if you purchase your insurance through an agent or directly from an insurance company, there may or may not be significant changes. Aetna, United Healthcare, Humana, and many other insurance companies will continue to provide health insurance coverage outside of the exchanges. But if your current health insurance company is leaving your health exchange, you need to choose a new insurance plan. And even if your insurance company is still in your exchange, you may choose to change plans to save money. There are usually several plans available to suit different needs.
As you have probably experienced, changes to your insurance plan, even if you stay with the same company, may affect your health care. Many providers and pharmacies accept multiple types of insurance, so you may be able to keep your doctors and pharmacies, but if a plan no longer covers your providers, you will need to change providers next year or pay out-of-network fees for your medical care.
Your Healthcare Needs
Healthy adults who only see a doctor occasionally and do not take regular medication will of course be least affected by these changes. But, the point of health insurance is to cover necessary medical care. The more care you need, the more important it is to know what care costs and who provides it. Plans do not always cover the best specialists or medications for every condition. If you or your dependents regularly see a physician or need prescription for a chronic health condition, and your doctor or medicine are no longer covered by the plans available to you this year, you might need to change your provider.
Location
Your location determines how much the changes in the health insurance exchanges will affect you and your healthcare. Families in many large metropolitan areas will continue to have a choice of several insurance providers, and that competition is helpful in keeping rates lower. Unfortunately, in some areas, you may only have one option on the exchange. Without competition, it is possible that the sole insurance provider will cut costs by limiting access to providers and what drugs are covered by their plan.
Smart Choices
If these changes in health care significantly affect you or family members you care for by limiting your choices or raising the cost of your health care, here are some smart choices you can make:
Research. Make sure you understand what your plan does and does not cover.
Shop around. Hire a broker to find plans that fit your budget and provide the coverage you want.
Use RefillWise. Insurance isn't the only way to afford needed medicine. RefillWise can save you money on prescriptions not covered by your plan, and in some cases buying a prescription with your RefillWise card may be less expensive than your insurance copay.
RefillWise is designed to save you money at the pharmacy. It fills holes in prescription coverage and gives you discounts if you don't have insurance.
But sometimes, just getting prescriptions authorized can take days or weeks or months, especially if you are one of the millions of people who use Medicaid for your primary or secondary insurance. Every prescription — whether for a drug, or a procedure, or equipment — requires an authorization. The backlog is sometimes more than 60 days just to receive your paperwork. Approval can take even longer. You can have your prescription denied because the paperwork wasn't correctly completed or it was missing a signature — or some other misunderstanding. Poor communication may delay — or prevent — getting needed medication.
This happened recently to Christine*. She was struggling with depression and needed medication to treat it. Her doctor prescribed her something, but she couldn't purchase her prescription immediately because she had to wait for authorization from Medicaid. Days went by while she struggled to manage her health. She called daily to check and the answer was always, "No, not yet."
In these types of situations, one of the most helpful resources is your State Senator or Representative. I contacted mine recently for an issue with Medicaid and I was amazed at how quickly our problem was solved.
Our Story
My oldest son is bright, funny, tenacious, and stubborn. He wants to be an engineer or a doctor when he grows up, or maybe a pirate. He's five, so he has time to decide. He loves to read, and his favorite subjects are math and science. But, if you met him, you wouldn't notice those things first. You would see the brace on his leg or the funny way he talks. You might notice that he has odd mannerisms and walks with a limp. That's because my son has a form of cerebral palsy called hemiplegia that was caused by a neonatal stroke.
He has difficulty using the right side of his body and also has a severe speech delay and several other learning and processing differences. He spends hours in therapy every week and uses devices like his orthosis and Alternative Communication Device that help him walk around and communicate. My son also needs regular treatments of Botox to help his muscles relax so he can walk.
Like many families with special needs children, we have two types of insurance for our child. We have primary insurance through an employer and we rely on Medicaid as our secondary insurance so that we can afford the therapies, devices, and treatments that help our son thrive. For every appointment or procedure our primary insurance is billed, just like normal — but anything they don't cover is billed to Medicaid. For instance, we use all of the 60 therapy sessions our primary insurance allows, but since that only covers about 10 weeks of the year, we use Medicaid to cover the rest. Just like with insurance, we have to prove that the therapy, device or treatment complies with Medicaid's strict rules.
Medicaid requires that our son be tested every six months to make sure he is meeting his therapy goals. They also take much longer to issue authorizations for his treatments and equipment than our private insurance does. It is a hassle, but it is worth it because the cost for all his medical needs is too much for us to manage without Medicaid.
Recently, though, I got a phone call saying that his authorization for therapies was denied. When I called Medicaid they said that someone at their company had flagged our son's authorization saying they needed a nurse to reevaluate if he really needed what the therapists prescribed. I spent hours on the phone talking with Medicaid and our therapy clinic trying to solve this and nobody seemed to know what was wrong or what to do next. Meanwhile, our son's therapy visits were cancelled because there was no insurance to cover them.
I was desperate, so I reached out to my State Senator Van Taylor hoping that I could at least give him some feedback about what was happening to real families using Medicaid as secondary insurance. To my surprise, someone from his office called me within an hour to ask if they could advocate for us with Medicaid. I signed the paperwork authorizing them to call Medicaid, and within a couple days someone from Medicaid called me back and the authorization was complete less than an hour later.
I'm so glad I reached out for help. Since then, I've learned a lot more about how State Senators and Representatives work. Their helpfulness was immediate and they showed genuine concern for us and our problem.
It is the job of our representatives to help advocate for us when we have problems with state services.
The Takeaway
If you have Medicaid coverage and can't get your prescription authorized, you are not without options.
Contact your State Senator or Representative to see if they can help you. You can find out who represents you here.
Call and check on the status of your authorization to see if you can help things go faster.
If you need a prescription and Medicaid has not yet authorized it, consider using RefillWise meanwhile to get a discount at the pharmacy.
Meet Katie*
Katie is a 31 year old single woman with a graduate degree. She works at a private school in Texas teaching children with profound special needs. Like many employees of small private schools, she doesn’t get health insurance through her employer. Katie is one of the millions of Americans who is underinsured even though she works full-time.
Katie’s Health History
Katie is a healthy adult who rarely gets sick. But she has anxiety, depression and obsessive compulsive disorder and has been on medications controlling her symptoms for years. She took a daily antidepressant and had Klonopin available for emergencies.
Katie’s Health Insurance Story
Until taking her current job, Katie had health insurance through her previous employer. Their plan was excellent and she only paid about $10 a month for her main prescription. But while the health insurance was great, the salary was low and the work environment was not good.
Katie found a much better position at a new school. The salary was higher, but the new school opted to not cover employees, instead sending them to the individual state health insurance exchanges. They assumed their employees should be able to get a better deal on the exchange. But when Katie applied to the exchange, she was told that she was not eligible for any discounts. Instead, she decided to go through an insurance broker who was able to get her the same plan she’d been on at her previous job at the same price as the plans she could get on the exchange, $260 a month. But after a year the plan was discontinued and she had to start again.
Meanwhile, the prescription she took was moving to generic. What had been a $10 prescription with rebates became a $50-60 medication as the manufacturer stopped honoring rebates. She switched to the generic when it came out and it went back down to $10 a month.
After her plan was discontinued, the insurance broker found her a plan that was the same price per month, but it was a High Deductible Plan. With this plan she had to pay out of pocket for everything up to $6000. High deductible plans can be a good option for people like Katie who are young and healthy, but they don’t cover prescriptions so she would have to pay out of pocket for those as well.
The total for her regular prescription without insurance was now over $370 a month. She couldn’t afford this so she made the difficult decision to go off the medication. Right before switching plans her doctor wrote her a 90 day prescription for weaning off the medication and she filled it. As she came off the medication her anxiety and depression worsened significantly. Because she had to go off her medication anyways, she recently switched plans again to a faith-based insurance that is less expensive and has a lower deductible, but doesn’t cover any mental health.
Life without these necessary medications is difficult and Katie doesn’t think going without her medications will work long-term. She is looking at her budget trying to find ways to cut expenses so she can afford to pay for what she needs, but as a private school teacher, her salary is limited and her budget is tight.
What can Katie do?
RefillWise can help Katie afford the prescriptions she needs. Since she can’t use her prescription insurance to cover the meds that keep her healthy, she can take RefillWise to the pharmacist and use it to receive a discount on her prescriptions.
Katie’s story may sound familiar. Many well-educated, Americans who work full-time are underinsured and unable to afford their monthly prescriptions. RefillWise fills in the gap between what your insurance covers and what your budget can afford.
*Her name has been changed to protect her privacy.
As the cost of healthcare continues to skyrocket, the employer sponsored insurance plan has turned into another way for insurance companies and employers to pass along a big chunk of that increase on to the 56% of Americans who have health insurance through their workplace — and yet another reason why it's more important than ever to check the prices of your medications with RefillWise. While many of us have seen copays for doctors visits and prescriptions increase, there are several other methods being used by employers and insurance companies to help pass along the cost to employees.
Remember that 50 slide power point presentation that HR gave during open enrollment? Not to worry, you aren’t alone. There are several important factors that make up your health plan, but for our purposes, premium and deductible are the two that matter most.
Your premium is the money that gets taken out of your paycheck along with your taxes, social security, and 401k if you have one. Your company actually pays 2 or 3 times that amount for you as well, and all of that combined money goes to the health insurance plan selected by your company.
One way that insurance companies first responded to rising costs was to of course raise the prices for premiums. Makes perfect sense, right? If they have to pay doctors, hospitals, and pharmacies more, they’ll just charge people more for access to the services. The problem, however, was that premiums simply became too high to afford. Between 1999 and 2005, workplace health insurance premiums averaged an increase of 11% every year. Since then, premium costs have slowed somewhat, but are still increasing at a rate of 5% a year.
2015 average monthly premiums
| Single Policy | Family Policy | |
|---|---|---|
| Employee Pays | $90 a month | $413 a month |
| Company Pays | $543 a month | $1,462 a month |
As a result of these increasing premiums, more and more employers are beginning to push High Deductible Health Plans, also known as catastrophic plans. A deductible is the amount of money you have to spend out of your own pocket before your insurance kicks in. Some plans still cover a basic checkup at the doctor, but nearly everything else from prescriptions, x-rays, specialist visits, and especially emergency care is 100% your responsibility until you meet that deductible. On the surface, a high deductible plan seems like a good fit for someone young and healthy. It comes with a much cheaper premium which saves the employee and the employer money, and it saves the insurance company money by greatly reducing their costs. The problem, however, is that these plans carry a lot of risk in case an employee ever actually needs medical care or especially if they need any prescriptions. Regularly prescribed medications that commonly cost only a $10 or $20 copay can cost $50 or $100 or even more with a High Deductible Health Plan.
Many employees with such plans are not aware of this negative consequence until the first time they go to a pharmacy to fill a prescription. RefillWise is a great idea for anyone with a high deductible plan who needs a prescribed medication. You can sign up and use it at any time to save money on your prescriptions instead of paying what is essentially the full cash price even though you have insurance. As premiums continue to rise each year and healthcare coverage continues to shrink, it’s more important than ever to be proactive. Take RefillWise to the pharmacy and make sure you’re not paying too much.
