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Neurology Now:
doi: 10.1097/01.NNN.0000453351.47896.32
Features: Health Insurance

Five Questions to Ask About Health Insurance: Whether you're thinking of buying an Obamacare plan or have already signed up, here's what you need to know.

Avitzur, Orly MD, MBA

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The Patient Protection and Affordable Care Act of 2010, commonly called the Affordable Care Act (ACA) or Obamacare, introduced into law several consumer protections that have come as a welcome relief to people with neurologic conditions. You no longer have to worry about being denied health insurance or getting charged a higher premium based on a neurologic condition, poor health status, or prior claims history. It's illegal for a health insurance company to arbitrarily cancel your benefits just because you get sick. New benefits introduced by the ACA include free care for preventive health services such as dietary counseling, aspirin therapy, and screening for blood pressure, cholesterol, and diabetes—important provisions that can help prevent cerebrovascular disease (such as stroke) and safeguard brain health.

Since ACA health insurance first became available in October 2013, more than 8 million people have enrolled, exceeding expectations. (Nearly 2.6 million signed up in the state-based marketplaces, and more than 5.4 million in the federally-facilitated marketplace). In more than a dozen states, including Texas, Georgia and Florida, enrollment doubled after March 1. But with such a rapid explosion of new plans suddenly in effect, patients are running into unexpected problems that can threaten their care.

So what do you need to ask if you've just started to use an ACA health insurance plan or are thinking of purchasing one when the open enrollment begins again for next year on November 15?

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WHAT BASIC PLANS ARE AVAILABLE?

1 Four types of plans are available through the ACA: Bronze, Silver, Gold, and Platinum. (Catastrophic high-deductible plans for people under 30 and people with financial hardship exemptions are also available.) Premiums are usually higher for plans that pay more out-of-pocket medical costs. For example, if you purchase a Platinum plan, you will likely pay the highest monthly premiums, but you will also have lower out-of-pocket costs when you go to the doctor or use another medical service. If you select a Bronze plan, you'll likely have the lowest premiums among these four metal tiers, but you'll be responsible for paying a higher share of costs when you receive care.

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WHAT ARE MY OUT-OF-POCKET COSTS?

2 The time to understand these fees, which are your share of your health costs, is before you buy a new plan. Much like leasing a car, how you set up the purchase plan will determine how much you have to pay at the time of service. But, unlike leasing a car, the prices of health services are not transparent. What's more, you may not be able to find out your share of the cost—for example, your co-insurance—in advance of treatment. Nevertheless, it's absolutely essential to understand that the cost of coverage is far more complex than just the premium due per month.

The three basic variables you must know about your health plan are the copayment, co-insurance, and deductible.

A copayment is a flat fee (for example, $25) you pay for a covered healthcare service with a participating provider, usually requested at the time of service. The amount can vary by the type of covered healthcare service. For example, my primary care copay is $15, whereas my specialist co-pay is $30. And be aware: if your neurologist provides more than one service, such as a test and an office visit on the same date, you may be responsible for more than one copayment at the time of your visit.

Co-insurance is your portion of the costs of a covered healthcare service, calculated as a percentage of the allowed amount for the service. For example, if your health plan's allowed amount for an office visit is $50, and you've met your deductible, and the co-insurance is 20 percent, your share would be 20 percent of $50: $10. The health plan pays 80 percent, the rest of the allowed amount.

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SHARE YOUR STORY

If you have enrolled in an Obamacare plan and have experienced any problems, we'd like to hear your story. Please email us at neurologynow@lwwny.com or mail it to: Neurology Now, 333 Seventh Ave., 19th floor, New York, NY 10001.

This is the tricky part: if you want a precise number, you must first ask your provider what the allowed amount is for each service. Sometimes, this cannot be determined until the service has been completed, but you can ask your doctor's billing staff for an estimate.

A deductible is the amount you owe for healthcare services your health plan covers before your insurance begins to pay. For example, my plan's deductible is $500, which means it won't pay anything until I've met that amount for the year (preventive care is excluded). Health plans configure and apply these fees differently. Under one plan, a comprehensive deductible might apply to all services, while another plan might have a separate deductible for covered services such as prescription drug coverage. In 2014, the maximum for individual out-of-pocket costs for in-network services is $6,350.

You may also have a family deductible amount, a sum of the out-of-pocket expenses of all family members that is counted until the deductible is satisfied, and an individual member amount that applies to each family member. The maximum for families in 2014 is $12,700. Health insurance plans purchased through the ACA tend to have high deductibles. If you have purchased a Bronze plan, you may not realize that you must spend several thousand dollars towards your deductible until your insurance kicks in. For example, if I had purchased an individual ACA insurance plan through Aetna in New York State, I would be responsible for paying $3,000 for health services at a cost of $513 per month before my plan began to pay my providers. A Platinum plan through Aetna would have cost me $823.00 per month, but my deductible would have dropped to $2,000. (To compare ACA plans in your area, go to healthpocket.com/individual-health-insurance.)

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IS MY NEUROLOGIST IN THIS PLAN?

3 Typically, health insurance plans sold through the ACA's marketplaces use narrow networks of providers: that is, they limit the providers their customers can use. If you see a doctor in the allowed network of participating providers, you will be responsible only for your out-of-pocket expenses as previously described, but if you go out-of-network, you will likely be responsible for all of the costs.

Unfortunately, finding out if your neurologist is in-network is not as easy as it should be. Most practices participate in more than a dozen insurance plans, and each of these may have several products. It's not enough to ask the receptionist at your neurologist's office, “Do you take my Anthem insurance?” Instead, you need to ask if your neurologist accepts the full name of the ACA insurance product, such as, “Do you participate in the Anthem Core DirectAccess Obamacare plan in Connecticut?” Finding out if your neurologist is in-network may take more effort than simply checking the insurance company's website or provider network manual, as these are not always up-to-date. Especially with new plans, they may be inaccurate.

To make matters even more complicated, your doctor may be in-network with several other health insurance products provided by your insurance company but may have elected not to join the Obamacare plan. Even if they do participate, the facilities they direct you to for services—such as the MRI scanning facility—may not. You need to inquire with each provider of service if they, too, participate in your specific insurance product.

Physicians' office staff may be unsure about their participation in an Obamacare plan as well. Many doctors, including neurologists, “opted out” of those plans because the fee schedules (panels of amounts covered per service) were not all defined prior to the opt-out date in 2012. That's like agreeing to sell your car to someone at a price he determines but will only disclose later.

Insurance company representatives may be confused about coverage; even the website could be incomplete or inaccurate. This dearth of accurate information is the subject of a lawsuit recently filed in California against Blue Shield. In their complaint, San Francisco residents John Harrington and Alex Talon accuse Blue Shield of misrepresenting the providers covered by their ACA plans sold on California's health exchange. According to the complaint, Harrington and Talon discovered that their providers were not covered only after receiving medical treatment numerous times between January and March, forcing them to pay the charges out-of-pocket. They sued on behalf of a group of other customers who had purchased similar plans from the insurer, only later to realize that the doctor and hospital networks for their plans were limited.

As a neurologist, I've had my own share of growing pains when it comes to Obamacare. A patient came to my practice in January, and my office verified her eligibility and benefits by telephone with the insurer, a small regional company. The company's representative provided us with information regarding the deductible (none) and co-payment ($45). When the patient arrived, we viewed and copied her insurance card; it appeared no different from the others we had seen for that insurance company. We later learned that the coverage was provided by an ACA product that we didn't accept.

Unfortunately, this scenario is being played out all across the country. A survey released in May by the Medical Group Management Association, the leading association for medical practice executives and leaders, found that 62 percent of respondents reported moderate to extreme difficulty with identifying a patient that has ACA exchange coverage as opposed to traditional commercial health insurance.

So keep track of all your conversations related to network participation: call each provider as well as your insurance company. Write down whom you've spoken with, the date and time of the conversation, and what was said. In the case of my patient, that's what we did, and the insurer was able to review the taped recording, and ultimately, pay the bill. Yes, it takes effort, but it will likely pay off.

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WHAT ARE THE LIMITATIONS OF MY DRUG COVERAGE?

4 One of the chief concerns for anyone who enrolls in a new health plan is whether their medications will be covered. For people with neurologic conditions, many of whom require treatment with costly drugs, this is especially important. Under the new law, all individual and small-group plans must cover at least one drug in every category and class in the U.S. Pharmacopeia, the official publication of approved medications in this country. Over-the-counter drugs are usually not covered, even if your neurologist writes you a prescription for them, and insurers can place limits on those medications they will pay for, covering only generic versions of drugs.

If your plan no longer covers your medication, you may be eligible for a one-time refill for your medication after you first enroll. If you can't get a one-time refill, you have the right to follow your insurance company's drug exceptions process, which may allow you to get a prescribed drug that's not normally covered. Generally, to get your medication covered through the exceptions process, your doctor must confirm to your health plan that the drug is appropriate for your medical condition based on the fact that other drugs covered by your plan haven't been or won't be as effective as the drug you're asking for, or that the alternative drugs covered by your plan have caused or are likely to cause side effects that may be harmful to you.

However, finding out what's on the formulary (the covered list of medications) can be challenging. An April report by Avalere Health, a market research firm, found that drug formularies are very or moderately accessible in only 52 percent of exchange plans. Thirty-eight percent of plans had no drug formulary data available, presenting significant obstacles to consumers who are shopping for insurance and attempting to determine the value of their coverage. Avalere also found that the insurance companies' links are not always direct, and in some cases, may redirect users to the insurer's homepage, which then requires them to navigate the website—with as many as six clicks—to find the appropriate documents. If you experience difficulties, call your health insurance plan and ask for a written Summary of Benefits and Coverage.

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IF I FAIL TO PAY MY PREMIUM, WHAT WILL HAPPEN TO MY BILLS?

5 The ACA grants a 90-day grace period to individuals purchasing subsidized coverage through state insurance exchanges. If you are receiving an advance premium tax credit—which can help make purchasing health insurance coverage more affordable for people with moderate incomes—you don't have to pay your premiums in full, and have a 90-day grace period. But if you fail to make your payments within months two or three, the insurance company can refuse to pay for the visit or ask your provider to return the reimbursed amounts. That's because a provision in the ACA law requires that insurers cover the first 30 days of treatment, but during the subsequent 60 days there are no guarantees. So, if you receive care during that period of time and your payment has not been received, your coverage will likely be cancelled and you could be held responsible for those bills incurred.

Despite these growing pains, most people, especially those who had not been able to afford health insurance before, appear pleased with their coverage. But knowing what to ask, and doing so before you sign up, should go a long way in helping you avoid the glitches and get the most out of your new coverage.

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FOR MORE INFORMATION

  • ▸ Consumer Reports Health Law Helper: A tool that helps you tailor the exchange product that best suits your age, income, employment status, and state in which you live, among other variables: healthlawhelper.org
  • HealthCare.gov: the federal government website that provides information about the Affordable Care Act and the Health Insurance Marketplaces
  • ▸ For more Neurology Now coverage of health insurance and other topics related to the cost of care, see our full collection of “Penny Wise” articles at bit.ly/NN_PennyWise
  • ▸ For articles on health insurance in Neurology Today, go to bit.ly/NT_HealthInsurance

© 2014 American Academy of Neurology

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