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Is Your Health Insurance Plan Special? PDF Print E-mail
Written by Ellen Breslow   
Tuesday, 08 July 2014 00:00
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It may be if it covers specialty drugs. Why is this an important component of a health insurance plan? You checked the drug formulary: no problem. Everything is covered.

Be careful. Prescription drugs have long been an important component of any health insurance plan. Most prescriptions (primarily generic substitutes) in employer sponsored plans have a co pay in the $10-$20 range, however, more recently in health insurance exchange plans, there are now drugs that are subject to hefty co insurance payments or aren't covered at all.

A co payment isn't a surprise for most participants; tier programs for prescription drugs have become a part of most health insurance plans. Prescription drugs fall into one of three tiers with copayment of $10, $20 and $50 respectively. The tier approach was designed to manage costs for both employers and insurers, however it is unlikely that tiers will stop the rise in drug costs for anyone, especially the participants of health insurance exchange plans.

Where are specialty drugs on the health insurance exchange formulary? Often nowhere. And if they can be found, they have a coinsurance percentage, not copayment attached. Frequently, individuals use specialty drugs for multiple sclerosis, rheumatoid arthritis and other illnesses. Many are 'biologic" which are used to treat rheumatoid arthritis when other treatments aren't effective. Most specialty drugs aren't available in a regular drugstore and are often delivered overnight in ice pack containers. While individuals have seen some specialty drugs on tier programs at employer sponsored plans, this is not always the case where health insurance exchange plans are concerned.

In a 2014, Avalere Health conducted a study to determine where specialty drugs fell in the metal hierarchy of plans in the health exchange system. Silver plans generally require that individuals pay 30 % of covered medical expenses. In the case of certain classes of specialty drugs, a fifth of the 123 formularies studied required 40% coinsurance payments for some classes of specialty drugs. Another 60% of the plans placed them in the highest tier which would require the highest coinsurance payment in the plan. Specialty drugs are among the fastest growing prescription drugs and some newer drugs could, in fact, be absent from the health insurance exchange formulary altogether.

If you're planning on enrolling in a health insurance plan for the first time this November, pay careful attention to the formulary, especially if specialty drugs are or may become a part of your medical care. Also, many individuals who purchased insurance through the federal exchange online at healthcare.gov may want to revisit their coverage if they are anticipating a specialty drug prescription for themselves or a family member before an automatic renewal takes place.

For additional information, contact EAB HealthWorks.


Last Updated on Tuesday, 08 July 2014 13:50
SHOPping for Health Insurance? May Be Slim Pickings PDF Print E-mail
Written by Ellen Breslow   
Thursday, 12 June 2014 00:00
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Small business owners who have been waiting to purchase health insurance through the Small Business Options Program (SHOP) exchanges for 2015 may find their selection of plans to be limited to one plan only. Although these small business exchanges will officially open for business in November, not all will offer a broad selection of plans.

The ACA established the new online SHOP exchanges to enable small business owners to purchase health insurance plans for their employees. These exchanges were created to permit small business owners to buy similar coverage as a larger entity to take advantage of the benefits that employees of large companies enjoy. Although some SHOP exchanges were open for the 2014 plan year, because of technical glitches, the federal government delayed the requirement that they be open for online applications until November.

The government is planning to operate the SHOP exchanges for 32 states. Given the technological requirements inherent in providing multiple plans for so many states, only 14 states within the federally administered exchanges will offer more than one plan in November. The remaining 18 states will have only one plan for 2015. While exchanges are expected to eventually present multiple plans to small business owners, these 18 states have been granted a transition year to accommodate new administrative requirements. Insurance carriers are expected to begin testing their plans on the exchanges by October.

What options are available to a small business owner if the SHOP exchange is a state run exchanage? That depends on the state. It's most likely that there will be multiple plans for the small business owner. But these exchanges vary from state to state, so visit the state's SHOP site for up-to-date information.

Stay tuned. The deadline for full service SHOP exchanges has been moved by the government more than once.


For additional information, contact EAB HealthWorks.


Last Updated on Thursday, 12 June 2014 11:25
Preventative or Diagnostic: Am I Covered? PDF Print E-mail
Written by Ellen Breslow   
Wednesday, 23 April 2014 00:00
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One of the cornerstones of the Affordable Care Act (ACA) is the ten essential benefits that include preventative services with no deductibles or copayments. The list includes an annual physical screening for a procedures such as a colonoscopy and a mammogram. But what if you go to your doctor for your annual physical and, at the same time, have the doctor look at your sprained finger?  Can this still be considered an annual physical? What if your physician suggests a subsequent appointment to update a screening? Is this part of your preventative services? Must all procedures be done in network?

Good questions. Maybe. Maybe not. Herein lies the confusion between preventative and diagnostic. And it's not only insurance companies that may have differing opinions on the subject.

There is a long list of what the ACA considers preventative care. Many of these screenings are accessible through blood work and most insurance companies will cover one preventative screening or visit per year with no charge to the policyholder. It is when this care is considered to be diagnostic that charges begin to accumulate and uncertainty ensues.

A colleague recently had what would be considered a routine colonoscopy. He is over age 50, therefore this procedure should be a preventative screening. During the procedure, the physician found polyps and sent them to a lab for further study. The polyps were noncancerous. Yet, although these polyps were located during a routine screening, the service was billed as diagnostic and my colleague was billed $520 for an in network provider. This seems to be a "catch 22"--how could the polyps be identified if there wasn't a preventative screening done?

Further question: if preventative services are covered at no cost to the individual, can the screenings be done anywhere? Health insurance carriers aren't required to allow subscribers to obtain services from any provider. Individuals should expect to go to in network services or face additional out of network charges.

Preventative or diagnostic? Some insurers have distributed educational literature for their subscribers to attempt to simplify this question. Not easy to simplify.

For additional information, contact EAB HealthWorks.


Last Updated on Sunday, 04 May 2014 14:44
You're a College Grad!--Now What About Your Health Care? PDF Print E-mail
Written by Ellen Breslow   
Monday, 12 May 2014 00:00
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You're a newly minted college grad or a parent of a grad. Congratulations! You have begun working, expect to begin working soon, or are out job hunting. Maybe graduate school. Or whatever comes next. Lots to think about as you contemplate your next steps.

Health insurance is probably NOT high on the list. So many young people don't want to think about health insurance until it is necessary to do so. This is especially true for college graduates starting out on their own. Some young adults have signed onto their parents coverage, and have the option of remaining a participant until age 26. For many, however, this is not an alternative.

If a student is covered by a college health plan, now is the time to check and see if there is a grace period during which the plan will remain in effect after graduation. Many university health plans extend coverage through the summer, which will give individuals time to review available options.

Open enrollment for health insurance exchange plans is over for 2014, however many college graduates may still be able to buy insurance through an exchange. The government offers several exceptions for people to enroll even after enrollment for the year closes. These "qualifying events" include loss of school based insurance, moving to a new area, and losing eligibility for a parent's plan at age 26, among other life events.

Many new college grads are fortunate enough to have landed a job where there is an employer sponsored health plan. New employees receive health insurance information when they begin work. Keep in mind that there may be a gap between when a university plan ends and an employer plan begins so that being mindful of coverage dates is important.

Two additional facts to remember: being uninsured even for a short period of time can be and expensive proposition in the event of illness or injury, and remaining uninsured can trigger an income tax penalty of up to 1% of income

For additional information, contact EAB HealthWorks.


Last Updated on Monday, 12 May 2014 10:25
The ACA for my college age kids PDF Print E-mail
Written by Ellen Breslow   
Monday, 14 April 2014 00:00
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It's routine now to hear high school seniors meandering in the hallways of their schools discussing what they are doing next year. College? Gap year? Other plans? On college campuses around the country students are planning for their graduations and their futures: Job? Graduate School? Don't know yet?

If you have children that fall into one of these categories, there is another issue that will weigh on your mind: health insurance. The Young Invincibles, as they are sometimes known, aren't so concerned about health insurance. But parents are, and with 2014 the year of the implementation of many of the Affordable Care Act  (ACA) provisions, should revisit the options available to both of the demographics.

Is your soon-to-be college freshman covered by your employer sponsored health insurance? That is most often the case with dependent children, even once they are planning to go to college. One of the first provisions of the ACA , effective in 2010, extended coverage to adult children through age 26. Now, with a child entering college, it makes sense to explore the health insurance that is offered by the college or university. It most often gives a student coverage that stays with them year round, on or off campus. The policies provide the benefits of a large group plan usually at a reasonable cost. Also, in 2014, with the establishment of state health insurance exchanges, you may find that an exchange plan would be an attractive alternative for your college bound student.

What are the options for your college grad with health reform in mind? If your grad is returning to live at home and employer based health insurance isn't an option, until age 26, a student can return to a parent's employer sponsored plan regardless of whether this coverage was used in college. As long as the parent remains employed and the employer sponsors the coverage, young adults can reestablish participation in the plan. If adult children have not been on the plan, however, their addition will raise the premium costs.

If your young adult becomes employed at an employer who is offering  a health benefit, the individual can enroll in that coverage even if he or she chooses to live with parents. Beginning in 2014, a young adult can also shop for coverage at a state health insurance exchange. The state exchanges now offer "catastrophic " coverage for individuals who are under age 30, in good health. These plans usually have lower monthly premiums, but higher deductibles. Catastrophic plans are an affordable way for a young adult to protect him or herself from the high cost of an accident or serious illness.

Don't let your child go away for the first time or graduate from college without a serious look at their health care coverage. For additional information, email ellen@eabhealthworks.com

For additional information, contact EAB HealthWorks.


Last Updated on Sunday, 20 April 2014 14:35
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