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‘Do The Math’ When Shopping For A Health Plan This Open Enrollment Season

‘Do The Math’ When Shopping For A Health Plan This Open Enrollment Season

By Julie Appleby, Kaiser Health News (TNS)

With the health insurance markets open for next year’s enrollment, Eve Campeau says she’s planning to look carefully at the fine print.

Last time she shopped, she switched to a plan with a lower monthly premium, but found herself paying far more out-of-pocket for medications and doctor visits. While she might be saving money on the premium, she is reluctant to go to seek medical care because of the upfront cost.

“It just becomes this whole guessing game: What is the least hit to the pocketbook?” said Campeau, 49, of Bedminster, N.J.

And it’s not easy to calculate. Nonetheless, experts say consumers who buy their own insurance under the Affordable Care Act should shop around, even if they’re already in a plan they like. They should spend the time doing the math to ensure their plan suits their situation.

Even then, estimating total costs will be a best guess.

That’s because, aside from set monthly premiums, other costs during the year will vary depending on an individual’s medical use.

Consumers who hardly ever see a doctor and don’t take any drugs, for example, could expect to have few other costs – unless they have an unforeseen health issue, like breaking a leg. Other consumers who know they take specific medications monthly or see certain specialists at regular intervals, should factor those costs into their calculations when selecting a health plan.

That’s especially true for prescription drugs. “They are one of the more predictable health care costs and … out-of-pocket costs for drugs are higher than for many other services,” said Caroline Pearson, senior vice president at Avalere Health, a consulting firm in Washington.

Drug coverage rules are dizzying, with consumers paying different amounts based on whether their medication is a generic, brand name or an expensive “specialty” drug. Costs vary by health plan and drug, from as little as $10 for generics, to more than 30 percent of the price of specialty medications, which may be hundreds or even thousands of dollars.

Many plans sold through the online marketplaces require consumers to meet an annual deductible before the insurer pays any medication costs – a condition that adds to the complexity.

An analysis by eHealth, an online broker, found that 91 percent of bronze-level plans, which have the lowest premiums, have an annual deductible that must be met before they cover part of the cost of prescriptions. Those plans have an average annual deductible of $5,889. More than half – 57 percent — of silver-level plans had a similar rule, while 43 percent of gold-level plans do. Twenty percent of the most expensive level of plan – platinum – includes drugs in the annual deductible requirement.

The bottom line is this: It’s not always obvious which plan will fit a consumer’s needs. Need help estimating costs? The federal and state marketplaces, and private online brokerages where consumers can shop for coverage,offer some calculator tools to help but they aren’t fully up and running.

Still, consumers shopping in the 37 states that use the federal website healthcare.gov can use a new website tool to get an idea of their estimated out-of-pocket costs. The tool asks consumers if they expect their health care use to be low, medium or high in the coming year, and then shows potential out-of-pocket costs for each available plan, factoring in such things as deductibles and co-payments for office visits and other medical services.

“It’s a blunt instrument, but helpful in at least educating people” about how costs can vary among plans, said Sabrina Corlette, project director Georgetown University’s Health Policy Institute.

Some state marketplaces, insurer websites and private commercial online Web brokers also have cost-estimator tools. EHealth.com and healthcare.com, for example, ask questions about expected medical use and give estimates of cost of various plans, with eHealth rolling out a way to incorporate the cost of specific prescription medications.

The District of Columbia’s website uses a tool developed by Consumers’ Checkbook that ranks plans based on expected total costs, including the premium, deductible, possible drug costs and other factors. The tool can also sort the plans based on a consumer having a “bad” medical year, or by insurer name. Consumers in Illinois, Missouri and Minnesota use a similar Checkbook-based tool.

Unfortunately for consumers, there’s no one set answer as to which type of plan will be the best value.

But there are ways to help narrow the choice.

If a consumer expects a high cost surgery or is taking an expensive drug, broker Brian Liechty in Plymouth, Indiana, suggests shopping for a plan with the lowest-out-of-pocket maximum, which is the annual amount the insurer can require the consumer to pay for in-network care or covered drugs.

Under the federal health law, the maximum out of pocket for 2016 plans is 6,850 for individuals and $13,700 for family plans. But some insurers offer plans with lower out of pocket caps, said Liechty.

Here are some other tips:

—Consumers taking any kind of prescription medication should check to see if it is covered under the plan’s formulary. If it’s not, consumers must switch to a different medication or pay the entire cost. The formulary also shows which payment “tier” the drug is placed by the insurer, determining how much the patient pays at the pharmacy counter. Insurers must include a link to their formularies for all their health plans on their own websites.

—Find out if anything is covered without having to first meet the annual deductible. Some plans will cover a few doctor visits – generally primary care – or prescriptions without the consumer first paying the full annual deductible, which can be thousands of dollars. Check the specific benefits of the plans under consideration to see if it waives the deductible for any doctor visits or drugs.

—Consider your income. Those earning up to 400 percent of the federal poverty level, or $47,080 for an individual, can get a tax credit to help cover monthly premiums. Those below 250 percent of the poverty level, or $29,424, can also qualify for plans with lower annual deductibles and smaller payments for doctor visits and drugs. Finally, consumers should consider their gut reaction: What level of financial risk can they accept? Some people prefer to lower monthly costs with the possibility of a high annual expense if a serious illness occurs. Others would rather pay more upfront in premiums, and less each time they go to the doctor or fill a prescription.

“What I try to measure is your tolerance for that,” Liechty said. “Does this plan make you feel safer than that other plan?”

(Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.)

©2015 Kaiser Health News. Distributed by Tribune Content Agency, LLC.

Photo: Experts say consumers who buy their own insurance under the federal health law should shop around and spend time doing the math to ensure their plan suits their situation. (Screenshot/TNS)

Ebola Patient Evacuated To US: Hospital

Ebola Patient Evacuated To US: Hospital

Washington (AFP) — A patient infected with the Ebola virus in West Africa is being evacuated to the United States and will be put in isolation, the hospital that will treat the unnamed person said.

Emory University Hospital, in Atlanta, Georgia, on Monday gave no details about the identity of the patient.

“The patient is being transported by air ambulance from West Africa. The patient is expected to arrive tomorrow morning. We do not know exactly what time the patient will arrive,” it said in a statement.

Americans Dr. Kent Brantly and aid worker Nancy Writebol have recovered from their Ebola infections, having been treated at Emory. A third infected American is being treated in Nebraska.

The death toll from the Ebola epidemic, which is spreading across West Africa, has surpassed 2,000, out of nearly 4,000 people who have been infected, according to the World Health Organization.

AFP Photo/Jessica Mcgowan

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MERS Patient Is Isolated In Indiana Hospital

MERS Patient Is Isolated In Indiana Hospital

By Juan Perez Jr. and Andy Grimm, Chicago Tribune

The man authorities cite as the nation’s first confirmed case of Middle East respiratory syndrome and dozens of hospital workers who first came into contact with him are being isolated from the public, in an effort to contain the potential spread of a deadly pathogen.

Medical workers at the Indiana hospital who have contact with the man are required to wear gloves, masks, gowns and eye protection. The man, who flew into O’Hare International Airport in Chicago from Saudi Arabia last month and was hospitalized days later, is being held in a room designed for patients with respiratory infections, and is segregated from the hospital’s air circulation system.

The patient needed oxygen during the first part of his stay, officials at Community Hospital in Munster, Ind., said Monday, but was not admitted to intensive care. Doctors said he’s now breathing regular air, is in good spirits and has a good appetite.

As the man’s condition appears to improve and nobody else has shown evidence of infection, officials provided the most detailed account to date of the seriousness of care with which public health and Centers for Disease Control and Prevention have taken to investigate and contain the potential spread of MERS in the United States.

About 50 hospital nurses, clerks, aides, dietary experts and other workers who came into contact with the patient before his infection was confirmed are on paid leave — isolated in their homes as experts watch for signs of symptoms and test for infection during the virus’ known incubation period.

The patient’s family members are in the same predicament. Those isolated at home have been asked to wear face masks if they leave the building, officials said.

At a briefing with Indiana and federal officials Monday, officials said the Saudi Arabian health care worker, who has not been identified but whom experts refer to as the “index patient,” is expected to return to home isolation with his family “very soon.”

But it’s unclear when the man, who officials said entered the U.S. through O’Hare while en route to a planned visit with Indiana relatives, will be able to travel or leave the country.

No one who has been isolated because of their contact with the patient has tested positive for the virus, officials said. Its incubation period lasts an estimated two to 14 days, and the patient first reported his illness at an Indiana hospital on April 28.

“We think this is well-contained, but we are exercising an abundance of caution,” said Dr. Daniel Feikin, a CDC epidemiologist and head of an agency response and investigation team sent to Indiana.

“I think it is promising that the staff that have had contact with him have already tested negative,” he said.

Feikin said the patient lives in Saudi Arabia and was working in a Riyadh hospital that housed MERS patients, though Feikin said the patient did not recall working directly with infected persons.

MERS is a new type of what scientists call “coronaviruses,” a widespread group of diseases that includes the common cold and pneumonia. The highly contagious SARS virus, which killed hundreds in Asia and North America in the early 2000s, is another kind of coronavirus.

First discovered in a Saudi Arabian patient in summer 2012, some experts believe MERS originated from an animal source because it’s been detected in camels and bats in the Middle East. MERS symptoms — fever, cough and respiratory problems — resemble those of influenza. Unlike the flu, however, there is no available vaccine or specific treatment recommended for the virus.

Health officials around the world have been particularly concerned about MERS because it is a new virus that scientists still have much to learn about, but has already proven to be quite lethal, with a recent CDC estimate showing it has killed nearly one quarter of the people who contracted it.

U.S. health experts aren’t certain where MERS originated, but say they’ve long expected the virus’ arrival to the country. Still, they say it currently poses low risk to the general public.

CDC officials said the patient flew from Riyadh to London, then onto Chicago before boarding a bus to Indiana on April 24. Roughly 100 people were on the patient’s flight to Chicago, officials said. Ten were on the bus.

The CDC has quarantine stations at ports of entry across the country, including one inside the international wing of O’Hare airport. But the patient did not identify himself as being ill when he cleared customs, Feikin said. His symptoms did not develop until after his arrival, Feikin said.

There is no active screening for passengers arriving from the Arabian Peninsula, Feikin said, nor are there any travel restrictions to countries in the region.

Nearly three-quarters of the patient’s fellow air travelers had been contacted, Feikin said, and none had exhibited any symptoms. State officials were working to identify bus passengers and officials in London are probing the Riyadh to Heathrow leg of the journey, Feikin said.

“We do know that he had limited exposure to the community once he arrived. He went directly to his family’s house,” Feikin said.

The patient arrived with family members at the hospital on the evening of April 28, said Dr. Alan Kumar, Community Hospital’s chief medical information officer. He was admitted to a private triage room, practitioner’s room and bed within three hours of his arrival.

But after confirming the man had contracted MERS, and considering the virus’ mysterious nature, officials pulled hospital workers from duty, Kumar said.

Officials used a variety of surveillance and recordkeeping tools to locate hospital workers who might have been exposed. They reviewed security camera footage to track the patient’s movements through the building and examined medical records to determine who was near him and when. The hospital’s health care workers are also tracked by a radio-frequency identification system, a hospital official said, which tells officials exactly where workers are at during a given time.

“If you think about it, you would think ‘Wow, that’s a ton of people,’ but we actually have 3,500 people who work on this campus on a daily basis,” Kumar said. Other workers have been called in to fill vacant shifts, Kumar said, and the hospital has been running its normal operations.

laurabillings via Flickr