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‘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)

Anthem Blue Cross Misled Obamacare Enrollees, Lawsuit Claims

By Julie Appleby, Kaiser Health News

LOS ANGELES — California insurance giant Anthem Blue Cross misled “millions of enrollees” about whether their doctors and hospitals were participating in its new “Obamacare” plans and failed to disclose that many policies wouldn’t cover care outside its approved network, according to a class-action lawsuit filed Tuesday.

As a result, many consumers are on the hook for thousands of dollars in medical bills and have been unable to see their longtime doctors, alleges the suit filed in Superior Court in Los Angeles by Santa Monica-based Consumer Watchdog. While declining to comment on the suit, Anthem has conceded that some doctors were inaccurately listed on its plans.

Brought on behalf of Anthem enrollees who purchased individual coverage between Oct. 1, 2013, and March 31, 2014, the lawsuit reflects growing consumer push-back against so-called “narrow network” health plans, which are increasingly common under the Affordable Care Act, commonly known as Obamacare. Anthem is a major player on California’s health insurance exchange, and the suit includes those who bought coverage online, as well as directly from the insurer.

The suit says that Anthem, the state’s largest individual health insurer, delayed providing full information to consumers until it was too late for them to change coverage. The suit also alleges that Anthem failed to disclose it had stopped offering any plans with out-of-network coverage in four of the state’s biggest counties — Los Angeles, Orange, San Francisco and San Diego.

Anthem spokesman Darrel Ng said that Anthem has agreed to pay the claims of those who received treatment from inaccurately listed doctors during the first three months of the year. However, he said, that policy would not be extended for enrollees who discovered after March 31 that their doctors had been incorrectly listed.

Anthem “intentionally misrepresented and concealed the limitations of their plans because it wanted a big market share,” said Jerry Flanagan of Consumer Watchdog.

The suit comes as the consumer advocacy group is pushing a measure on the November ballot that would give the state’s insurance commissioner greater authority to veto health insurance rate increases.

Insurers have defended plans with limited provider networks as a way of holding down premiums. Surveys have indicated that many younger and healthier customers are willing to give up broad access to providers for lower costs.

But consumers are retaliating with lawsuits and complaints to state regulators. As a result of the rising complaints, state managed-care regulators are investigating whether Anthem and Blue Shield of California provided accurate information about the doctors and hospitals in their plans.

The Consumer Watchdog lawsuit names six Californians who purchased Anthem plans. Among them is a Pasadena physician, Betsy Felser, who had coverage with Anthem for 20 years. Like hundreds of thousands of Anthem customers, she received a letter late last year stating that her preferred provider organization, or PPO, which allows for in- and out-of-network care, was being canceled, according to the lawsuit. The letter suggested a replacement Anthem plan “with the benefits you have come to count on.”

Before agreeing to switch, Felser said she checked with five Anthem telephone representatives, making it clear she wanted to be in a PPO.

“I would never have gotten anything that wasn’t a PPO plan,” said Felser, 47, whose insurance also covers her young son. “They said they would give me the same coverage.”

During those calls, none of Anthem’s representatives told Felser that the insurer was no longer offering PPOs in Los Angeles County, the lawsuit alleges. Nor did they tell her that the Anthem plans offered in her area would not cover care provided by out-of-network doctors or hospitals, according to the lawsuit.

Los Altos Hills residents Steven and Kathleen Moore were “fraudulently induced” into buying a Blue Cross “no deductible plan” that purported to include the family’s regular physicians, the suit says. In actuality, the suit adds, the plan imposed a $10,000 deductible for out-of-network providers and none of the physicians were included in the new limited network.

Fred Crary, of San Jose, a longtime but now former Anthem Blue Cross customer, said he’s not a fan of lawsuits. “But this is so important to families that I think it’s a good step that (Consumer Watchdog) is taking,” said the 59-year-old retired Silicon Valley tech executive.

Crary said Anthem “disenfranchised” people like himself and his wife after they discovered that their doctors would not accept their new Anthem plan, even after he said an Anthem representative had told him that his family’s doctors were on the new plan’s list of providers.

“I had no reason to believe they would not tell me the truth,” said Crary, who has since switched his plan to HealthNet, a similarly priced plan that most of his doctors accept.

The same thing happened to Therese Meuel after the Moraga mother signed her daughter up for an Anthem plan because she was told the girl’s pediatrician would accept the plan.

“They were very vague,” Meuel recalled when she asked an Anthem representative about how she could confirm that to be the case. She said the representative advised her to both check Anthem’s provider list and call the doctor’s office to be sure. Both sources confirmed the pediatrician was on the list. But a few months later, when she made an appointment with the pediatrician — who has taken care of her 17-year-old daughter since she was born — the office told her the doctor was not accepting her daughter’s plan.

Meuel supports the lawsuit, saying she hopes it “will get Blue Cross to get more doctors signed up on their list here.” She too has since switched her daughter to a different plan, offered by Blue Shield of California, that her pediatrician accepts.

AFP Photo/Karen Bleier