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New Coverage? Ask Yourself these Questions

Many people have new coverage in January although these tips apply whenever your new coverage may take effect. The purpose in actively managing new coverage is so that you anticipate the many changes you may face. Please ask yourself the following questions:

1. Have I received my new cards? If not, when should I call the insurer?

Waiting for new cards can be trying indeed. If you need your ID number before your cards arrive, you can usually obtain it by calling the insurer once you are in the benefit year. Ultimately, you do need to have your cards and they’ll normally arrive within three weeks of your effective date with the new Plan. Of course, if you’ve applied at the end of an open enrollment period, your cards may be at the end of the production queue.

2. Do I need to create new online portal access?

With new coverage, yes. You should create access with a new username and password and become familiar with the site. It may be possible to change to a different Plan offered by the same insurer and not have to create a new sign-in but make sure you have online access. Your site is an important source of information about coverage, claims, your network and rules.

3. Do I need to tell providers about new coverage?

Always. Most offices will ask about any information that has changed but that doesn’t always happen. And remember to update your information with your local pharmacy or pharmacy mail order service.

4. Do I understand the benefits of my new plan – also, what’s the deductible – how does it work – is it combined with pharmacy or is that a separate deductible?

It can be difficult to identify if benefit changes have been made but it is advisable to review the Summary of Benefits on your portal. I was delighted to learn last year that our Plan began to waive the deductible for many in-network services which greatly increased the value of the benefits.

5. Do I understand the provider network of the new plan? Is the network tied to a local geographic area or is it a national network? Do I have out-of-network benefits?

Understanding your network is critically important. Many people who’ve been enrolled in a PPO product with a national network mistakenly assume that all coverage is similar and it is not.

6. Are my preferred hospitals in-network with the new Plan?

Knowing if your preferred hospitals are in-network is also critically important and, hopefully, was factored into your decision-making about new coverage. Sometimes those with a significant medical condition who are actively undergoing treatment but forced to change coverage and networks will be provided a temporary period in which to make such a transition.

7. Are there any doctors I should consider changing so that I can remain in-network?

This is a very personal decision but if an objective is to minimize out-of-pocket expense, then you might consider changing doctors. If you have an out-of-network benefit, you’ll have some coverage for out-of-network doctors but out-of-network coverage is always limited.

8. Do I understand the rules of the new Plan? Do I need a primary care physician (PCP)? Do I need referrals?

Again, many who transition from an Open Access-type Plan with few restrictions in terms of rules are often surprised when it comes to dealing with a Plan that will require that you select a PCP and obtain a referral to see a specialist from that physician. Those who have an out-of-network benefit and intend to see out-of-network providers should also verify the claims filing deadline for their Plan.

Costly procedures and expensive drugs will likely require prior authorization from your provider no matter what the type of Plan so keep this in mind too.

9. Are all my drugs on the new Plan’s formulary? Is my pharmacy a preferred pharmacy with the new Plan?

The formulary is your Plan’s list of approved drugs. It’s not ordinarily a concern if an inexpensive drug is not on your Plan’s formulary but an expensive drug is a concern. In that case, you would request a formulary exception and the prescribing physician will likely be asked to write a letter in support of that request. If a formulary exception is denied, then you do have the right to appeal.

The significance of filling drugs at a preferred pharmacy varies. Sometimes there is very little difference in cost between a preferred and non-preferred pharmacy but this is an issue to keep an eye on because companies are aligning with one another to encourage customers to use preferred pharmacies.

10. What is my out-of-pocket maximum? Might I reach it?

If you’re in excellent health and anticipate a few visits a year, then you might not even meet your deductible so you won’t even approach your out-of-pocket maximum. Those who regularly use medical services should know what their out-of-pocket maximum is and track claims on their portal to anticipate if and when they might reach it. Remember, the out-of-pocket maximum is just that. You shouldn’t have to pay any more for in-network services, copayments and coinsurance, if you meet it. When you track claims on your portal and see that you’ve met the out-of-pocket maximum, you can say so if a provider office asks for payment. It is always better to avoid an overpayment than seek a refund.

11. (For those paying for coverage directly) Have I properly set up payment of the premium for my coverage?

Insurance companies will terminate your coverage for non-payment so don’t take any chances. We think auto-debit is the safest method to pay a premium.

Managing coverage can be onerous in situations like dealing with serious illness or when one member of a family is managing coverage for an entire family. Nevertheless, taking the time to be an informed consumer will help you effectively navigate our complex health system.

Please watch the video and thanks!