Consumer Reports’ Shop Smart: Your guide to the new insurance rules

Share with others:


Print Email Read Later

The new health care law has im­proved a lot of things about health in­sur­ance, ac­cord­ing to Con­sumer Re­ports. You can’t be turned down or charged ex­tra if you have a pre-ex­ist­ing con­di­tion, all types of ba­sic health ser­vices are cov­ered, plans can’t cap an­nual or life­time ben­e­fits and most pre­ven­tive care is free.

But in­sur­ance can still be com­pli­cated, and if you don’t fol­low the rules you can run into “got­chas” that can cost an arm and a leg.

Orly Avit­zur, med­i­cal ad­viser to Con­sumer Re­ports, lists five ques­tions you need to an­swer be­fore you see a doc­tor.

1. Is he or she in my plan’s net­work? That seem­ingly sim­ple ques­tion is any­thing but. The list on the health plan’s web­site might not be up-to-date, so it’s best to dou­ble-check first with the doc­tor’s bill­ing of­fice with the ex­act name of your plan.

2. What are the lim­ita­tions and ex­clu­sions? All plans have to cover “es­sen­tial health ben­e­fits,” such as phy­si­cians, hos­pi­tals, drugs, ma­ter­nity care, men­tal health care, tests, emer­gency care and re­ha­bil­i­ta­tion, but spe­cif­ics might vary. You’ll find those de­tails in the stan­dard­ized Sum­mary of Ben­e­fits and Cover­age form that all plans must sup­ply. Look to see if any ser­vices have lim­ita­tions (such as a ceil­ing on phys­i­cal ther­apy vis­its) or aren’t cov­ered at all (such as acu­punc­ture, den­tures or hear­ing aids).

3. Do I need a re­fer­ral or prior au­tho­ri­za­tion? With many HMOs, you need to get ap­proval from your pri­mary care phy­si­cian to see other doc­tors or ob­tain cer­tain tests or pro­ce­dures. If you don’t, the plan won’t pay. Don’t wait un­til the last minute, be­cause of­fices are in­un­dated with re­quests.

4. Will this test be cov­ered? A com­mon rea­son for a claim de­nial is that an in­sur­ance com­pany deems a ser­vice “not med­i­cally nec­es­sary.” You can save your­self an un­wanted bill by check­ing ahead of time with the in­sur­ance com­pany and your doc­tor’s bill­ing of­fice. Keep de­tailed notes on whom you spoke with and what they told you.

5. How will my med­i­ca­tion be cov­ered? Every health plan has its own for­mu­lary, or list of pre­ferred drugs, typ­i­cally or­ga­nized into as many as four tiers in as­cend­ing or­der of price. Tier 1 usu­ally in­cludes ge­neric med­i­ca­tion. You’ll prob­a­bly be re­quired to pay more for a pre­scrip­tion when a higher-tier brand-name prod­uct is dis­pensed. When start­ing a new drug, check your plan’s for­mu­lary to see what tier it's in. If it’s ex­pen­sive, ask your doc­tor or phar­ma­cist if a sim­i­lar drug in a lower tier would work as well.

Pay­ment terms

You’ll pay your share of health care costs in the fol­low­ing ways.

1. Out-of-pocket limit. The most you’ll have to spend from your own pocket for med­i­cal care in the pol­icy year. Once you hit that limit, your health plan will pick up 100 per­cent of any ad­di­tional costs un­til year’s end. The max­i­mum al­low­able “OOP” for 2014 is $6,350 for an in­di­vid­ual and $12,700 for a house­hold.

2. De­duct­ible. The amount you must pay for cov­ered ser­vices each year be­fore your in­sur­ance kicks in. Details might vary; one plan might have a sin­gle de­duct­ible, while an­other might have a sep­a­rate one for pre­scrip­tion drugs. With some plans, not all ser­vices are sub­ject to the de­duct­ible.

3. Co-pay­ment. A flat amount (for ex­am­ple, $20) you pay for a cov­ered health care ser­vice.

4. Co­in­sur­ance. Your share of the cost of a cov­ered ser­vice. With 20 per­cent co­in­sur­ance, for in­stance, if a CT scan costs $1,000 and you’ve met your de­duct­ible, your share of the cost will be $200.


By the ed­i­tors of Con­sumer Re­ports (www.con­sumer­re­p­orts.org).

Join the conversation:

Commenting policy | How to report abuse
To report inappropriate comments, abuse and/or repeat offenders, please send an email to socialmedia@post-gazette.com and include a link to the article and a copy of the comment. Your report will be reviewed in a timely manner. Thank you.
Commenting policy | How to report abuse

Advertisement
Advertisement
Advertisement

You have 2 remaining free articles this month

Try unlimited digital access

If you are an existing subscriber,
link your account for free access. Start here

You’ve reached the limit of free articles this month.

To continue unlimited reading

If you are an existing subscriber,
link your account for free access. Start here