Insurance plans and scams

When you have a chronic condition, it is really important to choose A CORRECT INSURANCE PLAN. Correct? Nope. The biggest travesty is that big employers sell to their employees high deductible insurance plans with low premiums. Low premiums sounds like a premium deal for you, right? Nope. Low premiums mean that you will avoid getting healthcare at all costs and you will save money for your employer. That plans cuts off your access to professional medical evaluation and medical insight. You do not know what you do not know. Do NOT undervalue your doctor! Health is wealth!

If you want to pick the right plan, then you need help navigating the maze of insurance options. That is increasingly complex every year. Whether you’re covered through your job or marketplace or the state, there’s plenty to sort out when if you have a chronic disease or take medications.

This blog will apply to both the Open Enrollment for the Marketplace and private insurance.After years of experience with choosing both individual plans, government plans and work plans, I have created this process to help your navigations as it applies to your health care.

 #1 Decide: What is your priority?

The 4  things that affect your health care costs.

1. Your primary care

2. Your specialists

3. Your budget - now and later

4. Your medications and equipment and YOUR LABS

5. Loss of productivity at work- which Evolve can help you with by offering appts on weekends and evenings and convenience.

WORD OF ADVICE FROM ME: THE INSURANCE COMPANY WILL ALWAYS GET ITS MONEY FROM YOU. WHETHER IT IS THE FRONT END OR THE BACK END. ALWAYS! I have calculated my healthcare costs in many many plans forwards and backwards. If you have any plans to get healthcare, then you will pay the same by the end of the year… period. “You cannot outsmart the thinker.” The insurance company is the think tank. They know the statistics and the calculations. They will not lose! So they most important things to identify is not the “COSTS” of co-insurance, 80%, 20%, blah blah blah…. Just check that your plan covers any of the healthcare that you currently depend on and avoid yourself a headache later. What matters the most is that you do not avoid paying for your healthcare because you will ultimately pay with your health and loss of productivity and vitality in life.

#2 Do not forget Key Dates

At the end of every year, you have a window of opportunity to sign up for next year’s insurance coverage in the Marketplace or your workplace that falls between November 1 and December 15.

There are qualifying events that will allow you to sign up for a new plan anytime from Jan 1 to Dec 15 and that is the start or end of a new job.

Any easy  rule of thumb: is that you do not wait for Christmas season to shop for insurance.

#3 What to Know about Employer’s Plans?

Workplaces typically offer plans that involve either

•      health maintenance organizations, called HMOs

•      Preferred Provider organizations, called PPOs

•      Possibly it offers a Point of Service POS or Exclusionary provider organization EPO, which are gaining popularity

•      HMO

•      PPO

•      POS

•      EPO

What does an HMO mean to your pocketbook?

With an HMO, the cost will be less with the plan covers only providers who are available within your network. Your primary care provider must give referrals for all of your specialist. You will need to make sure members of the Diabetes team such as your endocrinologist diabetes educator and dietitian are in your network, or you will pay out-of-pocket cost to see them, sometimes hundreds of dollars.

What does a PPO mean to your pocketbook?

Your plan is usually more expensive, but visits to out of network providers are covered at a higher rate, and in network but it’s often cheaper. For example your insurance may cover 80% of the cost of the visit for it in network provider and 40% out of network provider. Plus with a PPO you do not need to see your primary care provider for a referral in order to see a specialist, and that can save you time and money. It is really important to make sure that make sure that the doctor you want is in network, because if he isn’t then you’re still paying the other 60% for the out of network, and that is still really high priced.

What does a PSO mean to your pocketbook?

pso are comparable to PPOs but they just require a referral before you see a specialist

What does an EPO mean to your pocketbook?

EPO plan is like an HMO and that you must stay within the network, and anything out of the network means that you’re going to pay full price, but unlike an HMO you don’t need a referral to see a specialist.

Let’s go shopping for a plan….

WHOELSE BESIDES ME NEVER GOES TO THE STORE FOR ONE THING AND GETS DISTRACTED, FALLS PREY TO COLORFUL MARKETING AND COMES HOME WITH TEN THINGS.

When choosing a health insurance plan. There are a lot of options. I have created a system called “what is your priority?”

The best way to successfully choose the best option is to decipher: “what is your priority?” I will aid that by listing 4 priorities common to affording diabetes care.

As we walk down this aisle, keep your eyes on the target, and the target is YOUR PRIORITY.

You should know how each of these types of insurances: HMO, PPO, EPO and PSO will affect your costs in relation to your and the following information will explain essential points to know.

1Your whole healthcare team

2Your specialists

3Your budget

4Your medications and equipment

5Loss of productivity at work- which Evolve can help you with by offering appts on weekends and evenings and convenience.

Priority 1. Healthcare Team

If you are choosing your own individual plan privately and you love your current diabetes team members, then you might need to make sure and choose a plan where they are “ in network” if choosing .

Possible dilemma: Out of network provider

IF YOU’RE OFFERED A WORK PLAN BUT YOUR DIABETES CARE MEMBERS ARE OUT OF NETWORK… THEN YOU MIGHT OPT FOR A PPO THAT WILL COVER OUT OF MEMBER VISITS INSTEAD OF A CHEAPER HMO, WHICH could possibly REQUIRE YOU TO SWITCH PROVIDERS.

Remember that you do not have to choose your work plan and you can get your own plan.

Priority 2. Specialist Doctor

If you see a lot of specialists like an endocrinologist, cardiologist, neurologist, for example, you may not want to go through primary care doctor first, so a PPO or an EPO would be a good fit. But an HMO would make you go through the primary care doctor first.

It is best to always avoid switching specialists once established with one.

Possible Dilemma: Having many specialists such as diabetes, thyroid, heart, kidney….

Priority 3. Low budget

IF YOU WERE ON A TIGHT BUDGET AND THAT IS YOUR PRIORITY IN THE HMO MAY BE THE BEST OPTION IT IS LESS FLEXIBLE BUT IT IS ALSO THE CHEAPEST.

That’s an option to help you save money while on an HMO would be a flexible spending account.

Priority 4. Expensive Medications and Devices

Expensive medications will not vary in coverage based on the type of insurance plan that you have regarding whether it is an HMO PPO ESO etc.

Coverage for meds will vary from plan to plan based on different companies, Medicare, Medicaid and the cost of medications is based on the tier level of a formulary coverage and contracts with certain device companies

Dilemma: Exists in Formularies Contracts

Let’s go shopping for a plan….like a pro!

NOW THAT you have established a foundational basis for a health care plan by narrowing the options down to 4: HMO, PPO, EPO and PSO-- NOW HERE IS HOW TO NAVIGATE LIKE A PRO.

I will teach you how to do click by click, navigate based on “What is your priority?

•      I will teach you how to do click by click, navigate based on “What is your priority?

What is your priority?
Priority 1. Healthcare Team

Highly recommend that you check if your provider is in network before making a decision on a plan. IF YOU WANT TO KNOW IF YOUR PROVIDER IS IN NETWORK, THEN GO TO THE WEBSITE ON YOUR PLAN AND LOOK FOR A SECTION THAT SAYS CHECK FOR IN NETWORK PROVIDERS. IF YOU’RE STILL DOUBTING WHAT YOU’RE SAYING, THEN CALL TO YOUR HEALTH INSURANCE

What is your priority?
Priority 2. Specialist Doctor

ONE REASON THAT I RECOMMEND DOING THIS, IS BECAUSE IT IS A MUCH BETTER CONTINUUM OF CARE WHEN YOU STICK WITH THE SAME DOCTOR, GRANTED THAT YOUR DOCTOR IS DOING A GOOD JOB FOR YOU. A NEW DOCTOR WHO IS LEARNING ABOUT YOUR MEDICAL HISTORY WILL be less progressive with your medical care AT THE START.

What is your priority?
Priority 3. Low budget

CALCULATE UP YOUR ANTICIPATED EXPENDITURES. LOOK AT WHAT AREAS YOU’RE PLANNING TO SPEND ON. Your past history of MEDICAL spending can be a very good predictor.

Is diabetes education or a dietician covered?

How much are visits?

How much are labs?

What is your priority?
Priority 4. Expensive Medications and Devices

DO YOU ANTICIPATE MEDICAL DEVICES

DO YOU ANTICIPATE NAME BRAND MEDICATIONS LOOK UP on the website at the health insurance company which medications  ON co-pay level or TIER

If you are using a health insurance company that offers delivery, typically they do not except co-pay cards from the pharmaceutical companies

Navigating the maze of insurance options can be confusing. Whether you’re covered through your job or marketplace or the state, there’s plenty to sort out when you have a chronic disease like diabetes.