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Monday, September 5, 2016

The Search for an Individual Health Care Insurance Policy: Not as Easy as it Sounds






In this week’s post, I wanted to share a challenge I had as I went about the process of searching for an individual healthcare policy to replace my COBRA policy as it was expiring. 

Having healthcare insurance has never been so important to me because I realize that having a good policy allowed me to have access to providers and hospitals who saved my life when I was diagnosed with a life-threatening illness in November of 2014.  

Today, most people receive healthcare insurance through their employer as part of their employee benefit plan. For most of my career, I have been fortunate to have an employer-sponsored health care plan and thought little of how my employer put together the package they offered. For those who do not have health insurance offered by their employers, the Affordable Care Act has created a way individuals can buy insurance through the Market Place.

When I was not able to return to work in March 2015, I was offered COBRA by my employer. The COBRA policy allowed me to continue my health care insurance plan without interruption. This was a huge relief to me and my husband as the policy allowed me to have access to the doctors who had the expertise to diagnose and treat me for the brain tumor that threatened my life. If I did not have that policy, there is no doubt that we would be in a tremendous amount of debt and worse, I might not have survived. 

COBRA is a bridge that allows a person who has to leave their job to continue their insurance coverage till they can return to work or get an individual policy. In most cases, COBRA lasts for 18 months but under certain circumstances, can be extended to 36 months. Most people return to work and continue coverage under their employer-sponsored health care plan. Others use the opportunity to test the waters of independent practice. For those who do not return to full-time work, or their employer does not offer insurance, they have to search for an individual or family healthcare policy.

Finding a health care insurance policy to meet an individual needs is not an easy job. As most people do not have experience to understand what makes up a good policy,  many people turn to an insurance broker to help them understand their options or to the healthcare marketplace that was created by the Affordable Care Act.  

The Affordable Care Act has changed many of the rules that in the past made it difficult for people who had a medical or mental health condition (often referred to as pre-existing conditions) to purchase health insurance. Before the ACA, insurance companies could deny a person coverage because they had a medical condition as part of their medical history. 

As a result of the ACA, this is no longer possible. Today, when you look for an insurance policy, your medical history does not come into play. This has helped many people be able to purchase health insurance who in the past would have been denied.

The ACA has also changed how people search for insurance. In the past, many people worked with an insurance broker to learn about the policies available and which one’s met their needs. Brokers had the expertise to understand how policies worked and could give their clients advice that served them well. Most times people would choose the policy that allowed them to see the doctors who were currently treating them and go to the hospital where those doctors had privileges. With the development of Healthcare.gov and State Insurance Exchanges, brokers are being displaced, leaving the search up to the consumer. 

The platforms that are in place allow the consumers to search for insurance. They are not difficult to navigate and provide information that enables the consumer to make an informed decision by comparing various policies which are available.

The Healthcare Market Place is available to help people search for insurance. This task may be easier for people who do not have medical conditions and do not have a preference as to the doctors they see or the hospitals they prefer to be treated if they had an injury or a sudden illness. However, for those who have specific choices, the process is not as simple.

To control healthcare cost managed care companies set up provider networks which members have to use or pay higher out of pocket costs if they decide to go ‘out of network.' This has raised the bar and put pressure on the consumer, especially those who have medical conditions which require continuous care to make sure their doctors are part of the managed care network when they search for health insurance.

Another cost containment strategy many managed care companies are implementing are narrow networks. Narrow Networks limit the number and type of specialists that members have access. If you want a plan with a ‘wide network’, you will pay a higher premium or higher out of pocket costs. 

Some companies also have tiers and categorize providers and organizations according to their specialty and risk factors for the patients they see.  Specialists who provide care to complex patients are classified in a higher tier, so the consumer needs to pay higher out of pocket costs if they want to see a specialist. Providers and organizations who are in the higher tier categories have higher costs than those in lower tiers. Diagnostic testing, lab work, and other services like rehabilitation programs may also fall into tiered levels.

As a result of these things, looking for a healthcare policy is complicated and raises the cost of insurance for the consumer.

What is even more frustrating is that the managed care insurance companies can choose to pull out of an area when they find the area is not profitable,  leaving members to find new coverage and providers. Providers also are in a precarious position as their rates are negotiated by the the managed care network as part of their provider network contracts.

Another thing that was eye opening for me as I explored new policies was unlike other types of insurance you may purchase; you cannot purchase health insurance other than during the open enrollment period (November-January) or when you have a qualifying event.

As with many things related to healthcare, the system seems to be set up to benefit the insurance company instead of the consumer. To find effective and affordable coverage, the consumer has a tremendous amount of work as they navigate a complex system with strict rules, regulations and high costs.  Little training is available to help consumers understand the complex insurance industry so consumers need to take the time to learn the system as much as they can when they are in need of a policy.

Here are some tips that I learned from my experience of searching for an individual healthcare policy. 

  • Give yourself time. It takes time to find the right policy, so give yourself the time to do the research and find a policy that meets your needs.
  • As for help:  if you know an insurance broker, set up an appointment to discuss the process of buying health insurance.
  • If you do not know a broker, each State and county has Insurance Navigators who can help you understand the process. Navigators are familiar with the plans in your area and can help you find a policy to meet your needs. If you find yourself confused, don’t hesitate to ask for help.
  • Take time to get familiar with the technology in place that helps you search for health insurance. The two systems I used to during my search were Healthcare.gov and Costco. (Yes, Costco sells health insurance, and you do not need to be a member to use the system). Both sites were user-friendly and allowed me to view and compare various plans and their costs. If you have questions, both have assistance available. 
  • Make a list of what you would like to have in a policy. If you want to see certain doctors or go to a specific hospital, write the names down so you can check various managed care networks you are considering to see if those providers and organizations are part of the managed care network. You can do this online by going to the specific managed care organizations website and clicking on the tab that says find a doctor. Plug in the names of the doctors or facilities. These online provider directories are open for anyone to search.
  • Once you checked the online network, call the provider to verify they are in the network. Many times the online information is not up to date, and a provider may have dropped out of the network in-between network updates, so checking with them is another step in the process. Most doctors and hospitals are used to calls verifying network participation so don’t feel shy about asking.
  • As you look at policies, compare several to see which one’s meet your needs. In addition to checking for providers you want to see, look at the premiums, the out of pocket costs, and the deductibles of each policy so you can see the differences and decide what you can afford.
  • Depending on your income, you may qualify for a subsidy or tax credit from Healthcare.gov. A subsidy can help you afford a higher price plan, so it is worth checking out.
I am happy to say that I found a policy that I believe works for me. My qualifying event that allowed me to buy insurance outside of the open enrollment period was that my COBRA policy was expiring on September 30th. Unfortunately, my premium is going up, and I will have higher deductibles and out of pocket costs with this new policy. This is because my choices were limited I live in Florida, and many of the managed care organizations do not offer coverage in the State so choices are limited. 

I will only have the new policy for a few months, until the open enrollment period opens November 2016.  Once enrollment opens the manage care companies release what States and Counties they will provide coverage for 2017 and the cost of each plan. Once this information is published, I will be able to review the choices and make a change if want. 

Insurance companies are getting very picky where they offer policies. As a result, consumers had limited choices and are required to pay higher premiums so it is important to review your choices carefully. 

In closing, I urge everyone to stay informed and up to date on what is happening in healthcare. It is important time and your voice is important.

I plan to stay informed on the changes taking place regarding healthcare insurance on the local and the national level. As an experienced healthcare professional who has gone through the process, I have a good number of suggestions to share that would improve the process. I have sent ideas for improvements to the State of Florida Insurance Commissioner, my State Legislative officials and my members of Congress and the Senate. 

Thank you for reading this week’s post in Nurse Advocate. I hope this post provides you with information can use if you find insurance for yourself, a family member or a friend, who find themselves in a position of needing to find a health care insurance policy.

If you have a tip you would like to share, please post a comment in the comment section or email at allewellyn5@bellsouth.net

Have a good week!