You Now Have Health Insurance - Now What?

Now that Open Enrollment in Individual Health Plans is over (for most folks,) what do you do now?

For starters, go to either the webpage or the healthplan's book and check out what it is you actually purchased. You need to know three numbers - your premium, of course, your co-pay, and your deductible. When you selected your plan, you should have noted each of these numbers but many haven't. Please note them now for the true cost of your plan is not merely the monthly premium.

Now look at the "Provider Book" or the list of so-called Healthcare Providers on the plan website. Being a physician, let me point out that I didn't go to "Provider School." But that's a matter for another day. If you have an ongoing relationship with a doctor, make sure that your doctor is on the network list. If you can't find this information, call the plan's info number and find out. Again, you should have checked this out before choosing a plan, but that's water under the bridge now. Most if not all of the new individual plans set up under the "Affordable Care Act" are In-Network only plans and these networks are usually quite narrow with fewer choices. If after calling the plan and/or your doctor's office, emailing the plan, or sending out an APB, you still can't find out if your doctor participates in this plan, alert your state's insurance department. In NY State, that would be under the Department of Financial Services. Unfortunately for many, you may have to choose a new Primary Care Physician and you should do so asap. If you have a chronic illness for which you are undergoing treatment, you also have to find out if your specialist doctors are "in network" as well. If not, sadly, you will have to choose whether to pay a rather large bill for care or switch to a whole new set of treating physicians and start from square one.

Here's the problem - these new plans are for the most part "In Network" only. That means that whatever benefits your plan involve services provided only by In Network Providers. There are NO Out of Network Benefits for most Individual Plans save for a few scattered exceptions. If you need to go "Out of Network," the insurance version of "Off the Res," NONE of those services will be covered unless you get a special dispensation from the plan's hierarchy, usually the Medical Director. For example, if you have advanced colon cancer and wish to be treated at a Cancer Center like NY's Sloan Kettering which you find is not in your network, expect that you will be responsible for the entire bill. Moreover, and here's the kicker, none of the money you shell out will count toward your plan deductible - zip, zero, nada.

If you do not think this is fair, you are not alone. Unfortunately, the law isn't about fairness and it is what it is. My suggestion is that while you're still upset, you contact the State Insurance Dept (Again, in NY State, the Dept of Financial Services) and register a complaint. You should also call your state legislator and your local news consumer affairs reporter. The more light you shine on this issue, the sooner this will be dealt with. Everyone in NY State I've spoken with has acknowledged this problem with the individual plans.

Now, you may luck out. You may be healthy, not need care, and, if you do, find In Network doctors who are competent, caring and professional to handle your medical issues. But it shouldn't be left to luck, chance or God, should it?

Realize also that many doctors are in the same boat. It seems the plans were not so forthcoming at giving doctors the choice of either joining an insurer's new plan networks or informing them that they were either in or out of the new narrow network. This is a recipe for chaos. Also, if the plan lists a doctor as In Network but the doctor really is not, you will assuredly get a bill. And as I pointed out above, that bill will not count toward your deductible.

In reality, most of these plans are the worst of all worlds - an amalgam of an old HMO with a High Deductible Plan. There's little anyone can do about this situation right now, unfortunately. If you do run into a problem, please don't take it out on the doctor. Most of the doctors I know have been pleading with the states to do something as the end of enrollment approached. During the Second World War, the motto in Britain was "Keep Calm And Carry On." Both doctors and patients will need to do that. However, that doesn't mean you shouldn't complain. You should. For sure, it really is the squeaky wheel that gets the grease.

One last suggestion - other resources you should consider are your County and State Medical Societies. They have dedicate staff who are well-acquainted with the situation and are well-positioned to get you advice and also, to pursue your issues as they meld with their doctors' issues.

"Fasten your seatbelts, it's going to be a bumpy night." Bette Davis

Lemon of a Law

If PPACA, aka The Unaffordable Insurance Act, were a car, folks could recoup under the lemon law. We now know that if you like your plan, despite the president's "fix," you probably can't keep it. Some states like NY have already said it's too late to roll back that clock. Other states might be willing to go along but it depends on state regulators.

We also learn that if you like your doctor, you may not be able to keep your doctor. You may not be able to use your local hospital either, for that matter. Insurers have been both cutting their networks and decreasing their share of the payments to the doctors and hospitals for their services. Some prestigious NYC hospitals, like Langone Medical Center, have declined to participate in many of the new plans. Many doctors are also declining to participate or find (att some difficulty, I might add) that they've simply been dropped from the networks.

Without going into the Epic FAIL that is Healthcare.gov, many who are able to get to shop for insurance are experiencing firsthand the meaning of sticker shock. I guess that promise that folks would save about $2500 on their insurance costs was an "incorrect promise" also.

I ask you, when did we elect Joe Isuzu?

Smart Health Insurance Shopping

So you've seen those ads on TV and want to buy individual health insurance on the Exchange/Marketplace. You need to do some homework before you shop. The first thing you need to do is that if you have a doctor or doctors, you should make a list. It's important to know whether your physician will be participating in any of the plans you intend to buy. Remember the part in the President's speech about how you could keep your doctor? Well, that isn't necessarily so. 

If your doctor is not a plan participant, then you will have to consider the plan's Out of Network benefit. Some plans have better coverage than others. Also, many of the newer networks will have fewer, not more, physicians so Out of Network could end up being a major expense depending on your coverage.

You need to know is that the premium will not be the only cost associated with health insurance. The lower the premium usually means the higher the copayment and deductibles. This may not mean that much if you're young and without chronic illness, but if you find yourself seeing multiple physicians on a regular basis, these costs can add up quickly. The true cost of health insurance is much like the true cost of owning a car. The monthly payments are only a part of the story. 

Fortunately, you don't have to rush out and buy health insurance today. You have until mid-December to buy a policy whose coverage won't start until January 1. Ask questions. If you don't like what you're hearing, ask more questions. Make lists. Do your homework. To paraphrase the old Sy Syms commercial, an educated consumer is the best health insurance customer.