MONEY Health Care

Why You Could Get Stuck Paying for More of Your Health Care

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Your insurer may put a stop to how much it will spend on your surgery. iStock

A growing number of companies are capping what your insurance will pay for certain medical procedures. Get more expensive care, and you could be on the hook for the extra.

Aiming to contain health care costs, a growing number of employers and insurers are adopting a strategy that limits how much they’ll pay for certain medical services such as knee replacements, lab tests and complex imaging. A recent study found that savings from such moves may be modest, however, and some experts question whether “reference pricing,” as it’s called, is good for consumers.

The California Public Employees’ Retirement System (CalPERS), which administers the health insurance benefits for 1.4 million state workers, retirees, and their families, has one of the more established reference pricing systems. More than three years ago, the agency began using reference pricing for elective knee and hip replacements, two common procedures for which hospital prices varied widely without discernible differences in quality, says Ann Boynton, CalPERS’ deputy executive officer for Benefit Programs Policy and Planning.

Working with Anthem Blue Cross, the agency set $30,000 as the reference price for those two surgeries in its preferred provider organization plan. Members who get surgery at one of the 52 hospitals that charge $30,000 or less pay only their plan’s regular cost-sharing. If a member chooses to use an in-network hospital that charges more than the reference price, however, they’re on the hook for the entire amount over $30,000, and the extra spending doesn’t count toward their annual maximum out-of-pocket limit, Boynton says.

“We’re not worried about people not getting the care they need,” says Boynton. “They have access to good hospitals, they’re just getting it at a reasonable price.”

In two years, CalPERS saved nearly $6 million on those two procedures, and members saved $600,000 in lower cost sharing, according to research published last year by James C. Robinson, a professor of health economics at the University of California, Berkeley, and director of the Berkeley Center for Health Technology. Most of the savings came from price reductions at expensive hospitals.

The agency recently set caps on how much it would spend for cataract surgery, colonoscopies, and arthroscopic surgery, Boynton says.

Experts say that reference pricing is most appropriate for common, non-emergency procedures or tests that vary widely in price but are generally comparable in quality. Research has generally shown that higher prices for medical services don’t equate with higher quality. Setting a reference price steers consumers to high-quality doctors, hospitals, labs and imaging centers that perform well for the price, proponents say.

Others point out that reference pricing doesn’t necessarily save employers a lot of money, however. A study released earlier this month by the National Institute for Health Care Reform examined the 2011 claims data for 528,000 autoworkers and their dependents, both active and retired. It analyzed roughly 350 high-volume and/or high-priced inpatient and ambulatory medical services that reference pricing might reasonably be applied to.

The overall potential savings was 5%, the study found.

“It was surprising that even with all that pricing variation, reference pricing doesn’t have a more dramatic impact on spending,” says Chapin White, a senior policy researcher at RAND and lead author of the study.

Even though the results may be modest, a growing number of very large companies are incorporating reference pricing, according to benefits consultant Mercer’s annual employer health insurance survey. The percentage of employers with 10,000 or more employees that used reference pricing grew from 10% in 2012 to 15% in 2013, the survey found. Thirty percent said they were considering adding reference pricing, the survey found. Among employers with 500 or fewer workers, adoption was flat at 10% in 2013, compared with 11% in 2012.

The approach is consistent with employers’ general interest in encouraging employees to make cost-effective choices on the job, whether for health care or business supplies, says Sander Domaszewicz, a principal in Mercer’s health and benefits practice.

This spring, the Obama administration said that large group and self-insured health plans could use reference pricing.

The health law sets limits on how much consumers have to pay out of pocket annually for in-network care before insurance picks up the whole tab—in 2015, it’s $6,600 for an individual and $13,200 for a family plan. But if consumers choose providers whose prices are higher than a plan’s reference price, those amounts don’t count toward the out-of-pocket maximum, the administration guidance said.

Leaving consumers on the hook for amounts over the reference price needlessly drags them into the battle between providers and health plans over prices, says White.

“You expect the health plan to do a few things: negotiate reasonable prices with providers, and not to enter into network contracts with providers who provide bad quality care,” White says. “Reference pricing is kind of an admission that health plans have failed on one or both of those fronts.”

Some experts, however, say the strategy can work for consumers.

“What I think is that reference pricing is a choice-preserving strategy, when you look at the alternative, which is a narrow network,” says Robinson.

That may be a question of semantics, if relatively few providers meet the reference price.

Recent guidance from the administration spells out some of the requirements that health plans must meet in order to ensure that there are adequate numbers of high-quality providers if reference-based pricing is used. Among other things, it suggests that plans consider geographic distance from providers or patient wait times.

Like so much about reference pricing, it remains a work in progress. The administration says it will continue to monitor the practice, and may provide additional guidance in the future.

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

MONEY health insurance

Why You May Have to Spend More on Health Care Next Year

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Larry Washburn—Getty Images/fStop

When open enrollment kicks off at your workplace this fall, you should see only modest premium hikes. But you'll also come across more plans with higher out-of-pocket costs and surcharges to cover your spouse.

Fall is enrollment season for many people who get insurance through their workplace. Premium increases for 2015 plans are expected to be modest on average, but the shift toward higher out-of-pocket costs overall for consumers will continue as employers try to keep a lid on their costs and incorporate health law changes.

Experts anticipate that premiums will rise a modest 4% in 2015, on average, slightly higher than last year but lower than typical recent increases.

“That’s really low,” says Tracy Watts, a senior partner at benefits consultant Mercer.

Even so, more employers say they’re making changes to their health plans in 2015 to rein in cost growth; 68% said they plan to do so in 2015, compared with 55% just two years earlier, according to preliminary data from Mercer’s annual employer benefits survey.

They are motivated in part by upcoming changes mandated by the health law. Starting in January, companies that employ 100 workers or more generally have to offer those who work at least 30 hours a week health insurance or face penalties.

“The more people you cover, the more it’s going to cost,” says Watts.

In addition, experts say, employers are ramping up efforts to avoid a 40% excise tax on expensive health plans—those with premiums that exceed $10,200 for individuals or $27,500 for families—that will take effect in 2018.

More employees can expect to be offered high-deductible health plans linked to health savings accounts or health reimbursement arrangements in 2015. Nearly three-quarters of companies with more than 1,000 workers offer such plans, according to the 2014 Towers Watson/National Business Group on Health employer health care survey. Nine percent said they planned to add them in 2015.

For a growing number of employees, those plans may be the only ones available through work. For 2015, 30% of large employers said they expected to offer only an account-based plan to workers, nearly double the percentage that did so in 2014, the Towers Watson/NBGH survey found.

For some consumers, however, those plans raise concerns about the cost of care. A new survey by The Associated Press and the NORC Center For Public Affairs Research found that people with high deductible plans were twice as likely as those with traditional health insurance to report that they did not go to a doctor when sick or injured because of concerns about the costs.

When employers shift toward plans with higher deductibles, they often try to sweeten the deal for employees by offering to put money into the financial accounts to help defray the workers’ increased cost, says Brian Marcotte, president and CEO of the National Business Group on Health. The extra cash—an average $600 per employee—is often tied to wellness activities such as agreeing to get health screenings, says Marcotte. As employees evaluate their health plan offerings this fall, it’s worth checking to see if such incentives are offered.

Also this year, workers may find it increasingly expensive to cover their spouses, especially if they have coverage available through their own jobs.

Employers have been increasing workers’ costs to cover dependents, including spouses, in recent years. Nearly half of employers say they’ve hiked employee contributions for dependent coverage, and another 19% plan to do so in 2015, according to the Towers Watson/NBGH survey. Upcoming increases are particularly aimed at spouses, including $50 to $100 monthly surcharges for spousal coverage, says Sandy Ageloff, a senior consultant at benefits consultant Towers Watson.

“Legally under the Affordable Care Act, plans can’t exclude coverage for kids,” says Ageloff. “But they’re really trying to shift the onus back on to spouses.”

This fall, employees who work for small businesses may see fewer changes in their coverage than those who work for large companies. In March, the Obama administration announced that individuals and small businesses with plans that didn’t comply with health law coverage and cost requirements could be extended until 2017.

As many as 80% of companies with up to 50 employees opted to renew their non-compliant plans for 2014, says David Chase, national health care policy director at the Small Business Majority, an advocacy group. A similar percentage will likely try to do so this year as well, he says.

“That’s going to be a popular option for folks, if their states allow it,” Chase says. It’s up to states to determine whether insurers can continue to sell small group plans that don’t meet the requirements of the health law.

There could be a downside, however. “Sticking with the same plan doesn’t mean sticking with the same premium,” Chase says. “Those premiums could go up more than ACA-compliant plans.”

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

MONEY Ask the Expert

What Happens If You Get Your Obamacare Subsidy Wrong

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Robert A. Di Ieso, Jr.

Q. What happens to someone who has overestimated his income and received the wrong subsidy amount for a marketplace plan? Does he get a tax refund when he files? What if he underestimated his income and was paid too much? Does the system catch it when he reapplies for coverage in 2015? Will he be prevented from renewing automatically?

A. If you received too small a subsidy because you overestimated your income, that amount will be added to your tax refund—if you’re receiving one—or it will reduce the amount of tax that you owe, says Timothy Jost, a law professor at Washington and Lee University and an expert on the health law.

Similarly, if your subsidy was too large because you underestimated your income, you may have to pay some or all of it back. If your income is more than 400% of the federal poverty level ($94,200 for a family of four that enrolled for 2014), you’ll owe the full amount of any subsidy overpayment. At lower incomes, the amount that must be repaid is capped.

How your 2015 subsidy will be handled when you renew your coverage this fall will vary. If you live in one of the states where the federal government runs the health insurance marketplace, you may be automatically enrolled in a 2015 plan and, unless you contact the marketplace to update your income and other details, your subsidy amount will remain the same next year. That’s probably not in your best interest, since changing marketplace policy details and changes in your own financial situation could mean you either may not receive the total amount you’re due or you’ll be on the hook to repay a too-generous subsidy. The system, however, won’t prevent someone from renewing next year, automatically or otherwise, because his subsidy amount was incorrect.

“The best thing to do is to get in touch with the exchange to make sure they have the most up-to-date information,” says Jost.

States that operate their own marketplaces may handle enrollment differently. Those states may, for example, require everyone pick a new plan and update their subsidy eligibility information instead of simply auto-enrolling them, says Judith Solomon, a vice president for tax policy at the Center on Budget and Policy Priorities.

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

MONEY Medicare

What You Need to Know About Medicare Open Enrollment

Pharmacy
You can shop for a new drug plan starting October 15. Getty Images—Getty Images

Your once-a-year chance to change your drug coverage or switch plans begins in two weeks. Here's what to expect.

Medicare beneficiaries who want to make changes to their prescription drug plans or Medicare Advantage coverage can do so starting Oct. 15 during the Medicare’s program’s annual open enrollment period. There will be somewhat fewer plans to pick from this year, but in general people will have plenty of options, experts say.

And although premiums aren’t expected to rise markedly overall in 2015—and in some cases may actually decline—some individual plans have signaled significantly higher rates. Rather than rely on the sticker price of a plan alone, it’s critical that beneficiaries compare the available options in their area to make sure they’re in the plan that covers the drugs and doctors they need at the best price.

The annual open enrollment period is also a once-a-year opportunity to switch to a private Medicare Advantage plan from the traditional Medicare fee-for-service plan or vice versa. Open enrollment ends Dec. 7.

Although the Centers for Medicare and Medicaid Services has released some specifics about 2015 premiums and plans, many details about provider networks, drug formularies and the like won’t be available until later this fall. Here’s what we know so far:

Standalone Prescription Drug Plans

The number of Part D standalone prescription drug plans (PDPs) will drop 14%, to 1001 plans. This is the smallest number of offerings since the Medicare Part D program began in 2006.

Even so, “seniors across the country will still have a choice of at least two dozen plans in their area,” says Tricia Neuman, director of the Program on Medicare Policy at the Kaiser Family Foundation (KHN is an editorially independent program of the foundation.)

The drug plan consolidations that are driving the reductions in choices will likely shift many beneficiaries into lower cost plans, resulting in an average premium decline of 2%, to $38.95, according to an analysis by Avalere Health.

But that overall average premium obscures significant price hikes by some of the biggest plans. The average premium for the WellCare Classic plan, for example, will increase 52% in 2015, to $31.46, while the Humana Walmart RxPlan premium will rise 24%, to $15.67, according to Avalere.

Insurers are expected to continue to shift more costs to beneficiaries next year. The percentage of PDP plans with no deductible will decline to 42% from 47%, and, once again, about three quarters of plans won’t offer any coverage in the “donut hole”— the coverage gap in which beneficiaries are responsible for shouldering a greater share of their drug costs.

Underscoring the importance of evaluating plan options, 70% of standalone drug plan members will likely see their premiums increase if they stick with the same plans in 2015, says Ross Blair, senior vice president for eHealthMedicare.com, an online vendor.

Seniors, though, have historically not voluntarily switched plans in great numbers during annual enrollment. Between 2006 and 2010, on average only 13% did so, according to a 2013 analysis by researchers at Georgetown University, KFF and the University of Chicago.

Medicare Advantage

Enrollment in Medicare Advantage plans continues to grow: 30% of Medicare beneficiaries are now in the private plans, which typically are managed care plans that often provide additional benefits such as vision and dental coverage. Concerns that Medicare Advantage plans would disappear in large numbers as the health law gradually reduces their payments to bring them in line with the traditional Medicare program have proven unfounded to date. In 2015, the number of plans will drop by 3%, to 2,450, continuing a gradual decline.

“You still have lots of plans and robust selection,” says Caroline Pearson, vice president at Avalere Health, a research and consulting firm. Some parts of the country appear to be harder hit by plan reductions than others, including the Southeast and mid-Atlantic regions, Pearson says.

Medicare Advantage coverage has always been concentrated in health maintenance organizations, and this trend will continue in 2015. The number of HMOs will increase by 1.5%, to 1,747, while the number of preferred provider organizations will drop by nearly 9%, to 541, according to Avalere. About two-thirds of Medicare Advantage beneficiaries are currently in HMOs, while 31% are in PPOs.

The average premium will increase by $2.94 to $33.90, but nearly two-thirds of beneficiaries won’t see any premium increase, according to CMS. Like standalone drug plans, however, fewer Medicare Advantage drug plans will offer no deductibles and gap coverage, according to Avalere.

“It’s one example of how plans are tightening up coverage,” and pushing more costs onto consumers, says Pearson.

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

MONEY

Why You Can’t Wait Until You’re Sick to Buy Insurance

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Robert A. Di Ieso, Jr.

Q. Let’s say an uninsured person is in a car accident, has emergency surgery, and is hospitalized, and after awaking from surgery asks to purchase insurance right away. Under the health law, would his medical costs be covered since he can’t be denied insurance because of a pre-existing medical condition? An article I saw said the hospital would even enroll people and pay their premiums. Is that correct?

A. It’s unlikely that this hypothetical person would be able to sign up for coverage after being injured, says Judith Solomon, a vice president for health policy at the Center on Budget and Policy Priorities.

“It’s true that you can’t be denied because you have a pre-existing medical condition, but you generally have to sign up during an open enrollment period,” says Solomon. Employers generally offer insurance through an enrollment period in the fall. People buying coverage individually on or off the online marketplaces set up under the health law can sign up during open enrollment starting Nov. 15. But there’s a lag between when a person signs up and when coverage begins.

The reason for open enrollment is clear: If people could sign up anytime, chances are they would wait until they got sick to do so, wreaking havoc on the health insurance market that relies on spreading the insurance risk among sicker and healthier people.

Hospitals may sometimes pay premiums for patients’ existing policies or enroll people up front before they get sick. But in general it’s not possible to purchase coverage after you’ve already been injured and admitted to the hospital, says Solomon.

There is one important exception, however. Enrollment in a state’s Medicaid program for low-income people is open year round. If someone lives in a state that’s expanded Medicaid coverage to people with incomes up to 138% of the poverty level (currently $16,105 for an individual), enrollment would generally be retroactive to the first day of the month that the person applied for coverage. In addition, if someone was eligible for Medicaid during the three months preceding the application, medical care received during that time could be covered as well.

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

Do you have a personal finance question for our experts? Write to AskTheExpert@moneymail.com.

MONEY Health Care

New Ways to Handle the High Costs of Infertility

Empty crib with stork and baby on wall
Onur DAngel—Getty Images

Even with health insurance, couples face daunting expenses when they have trouble conceiving. Now a few organizations are stepping in with creative financing options.

Infertility treatment is a numbers game in some respects: How many treatments will it take to conceive a child? And how much can you afford?

Even as insurance plans are modestly improving their coverage of such treatments, clinics and others are coming up with creative ways to cover the costs to help would-be parents reduce their risk for procedures that can run tens of thousands of dollars. Some even offer a money-back guarantee if patients don’t conceive.

Shady Grove Fertility, a large center with sites in Maryland, eastern Pennsylvania, and Washington, D.C., has a number of programs to help people afford infertility treatment. The center pioneered a “shared-risk” program for in vitro fertilization (IVF) treatment years ago that offered a 100% refund if a couple didn’t have a baby. Now the center offers a similar program for couples who use donor eggs to conceive. Other fertility centers offer versions of these programs.

Both Shady Grove shared-risk programs allow couples to try up to six cycles of IVF or donor eggs for a flat fee. If they don’t have a baby, they get the full amount back; couples can also stop at any point in the process and get a full refund. The program costs twice as much as a single cycle—$20,000 for shared-risk IVF and $30,000 for shared-risk egg donor.

“In reality, patients who get a baby on the first cycle are subsidizing those who don’t get a baby,” says Michael Levy, president and IVF director at Shady Grove. “We see this as an opportunity to give patients security regarding the financial risk that they face.”

Tina and Jimmy Stone opted for the $30,000 shared-risk egg donor program. Tina’s uterus was healthy but her ovaries weren’t producing viable eggs. The Hollywood, Md., couple became pregnant with twins on the third try. The twin boys are now 2, and their daughter, who is adopted, is 8.

“For us, it was worth it,” says Tina, 35, who says the couple financed the shared-risk program through a private personal loan. “It kept our options open if it didn’t work, whereas if you pay per cycle, you’ve paid for nothing if it doesn’t work.”

A report by the ethics committee at the American Society for Reproductive Medicine found that shared-risk programs can be acceptable if patients are fully informed about the criteria for success and program costs, among other things.

Shared-risk and other programs are popular in part because health insurance coverage for infertility treatment, while slowly improving, is still sparse. Fifteen states require insurers to cover infertility treatment to varying degrees, according to Resolve, an infertility advocacy group. Among employers with more than 500 workers, 65% cover a specialist evaluation, 41% cover drug therapy, and 27% cover in vitro fertilization, according to human resources consultant Mercer’s 2013 employer benefits survey. Thirty-two percent of large companies don’t cover infertility services at all.

Glow is one of the most recent companies to offer a program to help address the financial uncertainties around infertility and treatment. The company, which is best known for an app that helps women track ovulation and other pregnancy-related health data, started Glow First last August for couples worried about infertility.

Participants pay $50 monthly for up to 10 months. The money is pooled with contributions from people who also started the program that month. At the end of 10 months, those who haven’t become pregnant split the pot of money; Glow will pay their share to an accredited infertility clinic once they submit their bills for fertility testing or other services.

The program isn’t open to people who’ve already received treatment for infertility.

The first group that began contributing in October 2013 has just ended. Roughly 50 people participated, according to the company. The average age was 34, and the typical participant had been trying to get pregnant for a year. The payout to those who didn’t become pregnant was $1,800.

“This relatively minimal contribution will help to offset those downstream and very high costs” of fertility testing and treatment, says Jennifer Tye, Glow’s head of marketing and partnerships.

There are other ways to manage the cost of infertility treatment. In addition to shared-risk programs, many fertility clinics offer other discounts and financing options to help couples afford treatment. Other companies also offer financing and/or infertility insurance to help cover the costs for couples who are working with a surrogate to have a baby, for example, or for IVF treatments.

“I think it can be confusing for people,” says Barbara Collura, president and CEO of Resolve. “There’s no one place to go to learn all the different financing options.”

Most fertility clinics have someone on staff who will sit down and and talk with prospective patients about the costs they’ll be responsible for and financing options that are available, says Collura.

“Exhaust all the obvious choices with your insurance and whatever financing programs the clinic might participate with,” says Collura. “Then do research to fill in.”

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

MONEY Health Care

Why a Trip to the ER Could Cost You More Than You Expect

If a holiday weekend mishap sends you to the emergency room, watch your wallet. You shouldn't owe more if the hospital is outside your insurance network. But that could change if you're admitted.

When you need emergency care, chances are you aren’t going to pause to figure out whether the nearest hospital is in your health insurer’s network. Nor should you. That’s why the health law prohibits insurers from charging higher copayments or coinsurance for out-of-network emergency care. The law also prohibits plans from requiring pre-approval to visit an emergency department that is out of your provider network. (Plans that are grandfathered under the law don’t have to abide by these provisions.)

That’s all well and good. But there are some potential trouble spots that could leave you on the hook for substantially higher charges than you might expect.

Although the law protects patients from higher out-of-network cost sharing in the emergency room, if they’re admitted to the hospital, patients may owe out-of-network rates for the hospital stay, says Angela Gardner, an associate professor of emergency medicine at the University of Texas Southwestern in Dallas who is the former president of the American College of Emergency Physicians.

“Even if the admission is warranted, you are subject to those charges,” she says.

If you live in a state that permits balance billing by out-of-network providers, your financial exposure could be even greater. In a balance-billing situation, a hospital may try to collect from the patient the difference between what the hospital billed and what the health plan paid for care. Such practices aren’t generally allowed if a consumer visits an in-network provider.

Consumers shouldn’t expect that the hospital will inform them of potential out-of-network coverage issues, so they need to inquire, says Gardner.

“At least being informed and knowing what you’re getting into can set you up to handle it with your insurer,” she says.

And while you’re at it check into being transferred to an in-network facility if it’s feasible.

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

MONEY Health Care

How Some Insurers Still Avoid Covering Contraception

Locked up birth control pills
Nicholas Eveleigh—Getty Images

Under health reform, your birth control should be fully paid for by insurance. But even before the Supreme Court gave more employers an out, some insurers have been pushing back.

How much leeway do employers and insurers have in deciding whether they’ll cover contraceptives without charge and in determining which methods make the cut?

Not much, as it turns out, but that hasn’t stopped some from trying.

Kaiser Health News readers still write in regularly describing battles they’re waging to get the birth control coverage they’re entitled to.

In one of those messages recently, a woman said her insurer denied free coverage for the NuvaRing. This small plastic device, which is inserted into the vagina, works for three weeks at a time by releasing hormones similar to those used by birth control pills. She said her insurer told her she would be responsible for her contraceptive expenses unless she chooses an oral generic birth control pill. The NuvaRing costs between $15 and $80 a month, according to Planned Parenthood.

Under the health law, health plans have to cover the full range of FDA-approved birth control methods without any cost sharing by women, unless the plan falls into a limited number of categories that are excluded, either because it’s grandfathered under the law or it’s for is a religious employer or house of worship. Following the recent Supreme Court decision in the Hobby Lobby case, some private employers that have religious objections to providing birth control coverage as a free preventive benefit will also be excused from the requirement.

In addition, the federal government has given plans some flexibility by allowing them to use “reasonable medical management techniques” to keep their costs under control. So if there is both a generic and a brand-name version of a birth-control pill available, for example, a plan could decide to cover only the generic version without cost to the patient.

As for the NuvaRing, even though they may use the same hormones, the pill and the ring are different methods of birth control. As an official from the federal Department of Health and Human Services said in an email, “The pill, the ring and the patch are different types of hormonal methods … It is not permissible to cover only the pill, but not the ring or the patch.”

Guidance from the federal government clearly states that the full range of FDA-approved methods of birth control must be covered as a preventive benefit without cost sharing. That includes birth control pills, the ring or patch, intrauterine devices and sterilization, among others.

But despite federal guidance, “we’ve seen this happen, plenty,” says Adam Sonfield, a senior public policy associate at the Guttmacher Institute, a reproductive health research and education organization. “Clearly insurance companies think things are ambiguous enough that they can get away with it.”

If you are denied coverage, your defense is to appeal the decision, and get your state insurance department involved.

“The state has the right and responsibility to enforce this law,” says Sonfield.

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

More on the Affordable Care Act and contraception coverage:

 

 

 

 

 

MONEY Health Care

How to Pick a Health Plan That’s Right For You

Picking a card with medicine on it
David Emmite—Getty Images

HMO, PPO, EPO? The alphabet soup of insurance plans may leave you dazed and confused. Here's how to make sense of your choices and get the coverage you need.

What’s in a name? When it comes to health plans sold on the individual market, these days it’s often less than people think. The lines that distinguish HMOs, PPOs, EPOs, and POS plans from one another have blurred, making it hard to know what you’re buying by name alone—assuming you’re one of the few people who know what an EPO is in the first place.

“Now, there’s a lot of gray out there,” says Sabrina Corlette, project director at Georgetown University’s Center on Health Insurance Reforms.

Ideally, plan type provides a shorthand way to determine what sort of access members have to providers outside a plan’s network, including cost-sharing for such treatment, among other things. But since there are no industry-wide definitions of plan types and state standards vary, individual insurers often have leeway to market similar plans under different names. In general:

  • Health maintenance organizations (HMOs) cover only care provided by doctors and hospitals inside the HMO’s network. HMOs often require members to get a referral from their primary care physician in order to see a specialist.
  • Preferred provider organizations (PPOs) cover care provided both inside and outside the plan’s provider network. Members typically pay a higher percentage of the cost for out-of-network care.
  • Exclusive provider organizations (EPOs) are a lot like HMOs: They generally don’t cover care outside the plan’s provider network. Members, however, may not need a referral to see a specialist.
  • Point of Service (POS) plans vary, but they’re often a sort of hybrid HMO/PPO. Members may need a referral to see a specialist, but they may also have coverage for out-of-network care, though with higher cost sharing.

Although insurers identify plans by type in the plan coverage summaries they’re required to provide under the health law, one PPO may offer very different out-of-network coverage than another.

“You have PPOs with really high cost sharing for out-of-network services, which from a consumer perspective seem a lot like HMOs,” says Corlette. Some plans labeled as PPOs don’t offer out-of-network services at all, experts say. On the other hand, some HMOs have an out-of-network option that makes them seem similar to PPOs.

Then there are EPOs. “People have no idea what an EPO is,” says Jerry Flanagan, lead staff attorney at Consumer Watchdog, an advocacy organization that recently filed a class action lawsuit against Anthem Blue Cross in California. They claim, among other things, that the insurer enrolled people in EPO plans with no out-of-network coverage who believed they were being enrolled in PPO plans that provided such coverage.

“Materials at the time of enrollment and in member’s Explanation of Benefits have clearly stated that the plan was an EPO plan which may not have out-of-network benefits,” said Darrel Ng, a spokesperson for Anthem Blue Cross, in a statement.

This year, HMOs and PPOs dominated the plans offered by insurers on the health insurance exchanges. According to an analysis of plans sold in the 36 states for which the federal government runs the online insurance marketplace as well as the plans sold on the California exchange, HMO offerings made up 40% and PPOs another 40%. POS plans made up 12% and EPO plans 7%.

Higher premiums didn’t necessarily correlate with better out-of-network coverage, says Caroline Pearson, vice president at Avalere Health, a research and consulting firm. HMO plan premiums, in fact, were slightly higher on average than those for PPOs, according to the Avalere analysis.

Pearson says the explanation may be that insurers anticipated that people who bought a PPO would probably want to use out-of-network providers. Since out-of-network spending doesn’t count toward the out-of-pocket maximum that people are responsible for before insurance picks up the full tab, these people were likely to be cheaper to insure, she says. (Next year, the out-of-pocket maximum will be $6,600 for single coverage and $13,200 for a family plan.)

Based on the 18 states that have released their proposed products and rates for next year, it doesn’t appear that plan types are likely to change significantly, says Shubham Singhal, leader of the health care practice at management consultant McKinsey & Co.

“Perhaps a few more EPOs will emerge,” he says. “Some of the health plans that might have introduced metal-level plans through the HMO are viewing the EPO as way to introduce a non-gatekeeper product.”

Since you can’t rely on plan type to provide clear guidance on out-of-network coverage, there are three basic questions to investigate when evaluating a plan, says Pearson:

  • Is there out-of-network coverage?
  • Does that out-of-network spending accrue toward the member’s out-of-pocket maximum? Legally it doesn’t have to, but some plans include it.
  • Do members need a primary care physician gatekeeper?

That’s only the beginning. Once you figure out whether a plan covers out-of-network care, it can be difficult to find out whether your doctor is even in that plan. You can check with you doctor’s office, but sometimes they don’t know. You can also look at provider directories to see who is and isn’t in a plan’s network, however, that information frequently proved inadequate or inaccurate last open enrollment period. But understanding the alphabet soup of plan types is an important first step.

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

MONEY Ask the Expert

When Parents Can Say No to Picking Up the Tab for Insurance

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Robert A. Di Ieso, Jr.

Q. My ex-husband has been responsible for providing health insurance for our kids until the age of majority. My sons are now 21 and almost 18. My ex has family coverage for himself and his new wife, but he wants me to put the kids on my insurance now that they have reached the age of majority. Covering the kids doesn’t cost him anything extra, but for me to switch from a single plan to a family plan is an extra $175 a month and I can’t afford it. Since the age of majority for health insurance is now 26, is it possible he still is required to keep them on his insurance?

A. No, he’s not obligated to keep them on his health plan. Under the health law, insurers must offer to cover young adults up to age 26, but parents aren’t obligated to provide it, says Timothy Jost, a law professor at Washington and Lee University and an expert on the health law.

Further, the requirement to offer coverage isn’t related to the age of majority, which is defined by individual states and is generally between 18 and 21, says Randy Kessler, an Atlanta divorce lawyer and past chair of the American Bar Association’s family law section.

The health insurance coverage arrangement that you describe is pretty typical, says Kessler. You could go back to court and try to get your child-support payments increased to cover the cost of providing health insurance for the kids, but “it would be unusual for the courts to be helpful,” says Kessler. Absent some significant change in your or your ex-husband’s finances, or unforeseen and costly medical expenses for your children, in general “you can’t have another bite at the apple.”

With no legal requirement to compel either of you to cover your kids, it’s something the two of you will just have to work out, says Kessler. In addition to covering your children on your own or your ex’s plan, it’s also worth exploring whether they might qualify for subsidized coverage on the state marketplaces or for Medicaid, if your state has expanded coverage to childless adults. If they’re in college, student health coverage is worth investigating as well.

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

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