For most employees, October means open enrollment for benefits, including health insurance. Elections are made for the coming year and are irrevocable unless there is a family event such as marriage or the birth of a child. A study conducted by EHealthInsurance in late 2011 indicated that 52% of those respondents who have health insurance at work will keep the same coverage going forward. The actual percentage is likely greater than this poll indicates. Given the rising cost of health care don’t be part of the employee group that makes the same elections with no review of family needs.
Many employees don’t review coverage options because aside from premiums and deductibles, they aren’t familiar enough to group the difference between the plans. Consider these components of health insurance:
Out of pocket costs: In addition to premiums and deductibles, co-insurance is the portion of the claim that the insured is responsible for after meeting the deductible. Many plans also have copayments that apply to doctor’s visits. Specialists may have a higher copayment. If you and your family go to the doctor frequently, these fees can add up quickly. Most likely, your plan will have an out-of-pocket maximum; if medical expenses reach that point, the insurance company will assume the costs. But the maximum will be so high that you will be responsible for significant expenses before the insurance company steps in.
Prescriptions: Over the past 5 years, the menu of generic drugs has grown, so that many medicines that were cost prohibitive now have generic substitutes. Certainly people have become accustomed to asking for generic drugs, and these prescriptions are covered at a fraction of the cost of the brand name equivalent. Not every prescription has a generic substitute, so it is critical that drug coverage be scrutinized. Insurance plans have a “tier” system where the drugs are placed selectively by tier. A member may pay $10, $20 and $40 depending upon the tier. The tier prices can vary, but depending on the medication, it may not appear on any tier and have no coverage. Review the drug plan carefully before enrolling in a plan.
Specialty Drugs: These medications usually, but not always, fall outside of the generic/brand name category. Also known as biologics, these drugs typically have no generic substitute. Often they are injections delivered refrigerated to a patient’s home or doctor’s office. Many medications are being developed this way, and often the cost per dose is north of $2000. Insurance companies engage a third party pharmacy that specializes in the preparation of biologics to fill prescriptions. Some health plans cover a portion of a specialty drug; see if your health plans do.
Wellness: If you haven’t taken exercise and nutrition seriously, now is the time. Employers can offer a less expensive health care plan to those employees who follow a weight loss or a quit smoking program. Premiums can often be discounted if employees can demonstrate their adherence to a supervised program.
The best idea is to make a list of what’s important to you and your family when selecting your health care election for 2013. Spend your health insurance dollars wisely.
Need help? Email Ellen at EAB HealthWorks.