Caveat Emptor-Have HMOs Returned?

Press outlets are discovering the narrowed provider networks that insurers are implementing in Affordable Care Act-compliant individual health insurance plans.  Click here for a recent buzz-worthy story from the New York Times .

With pressures to flatten the premium inflation curve created by the Affordable Care Act, we expect to see more of these efforts in the years ahead.  This article is a reminder that health coverage isn’t an impulse buy- it’s an important part of your personal financial planning that requires due diligence, research and expertise.  Making sure your doctors are in-network providers, or preparing for a change in physicians is just one of many steps in the buying process.  Checking to make sure medicines are covered by a plan formulary is equally important.  Closed formularies on new ACA-compliant plans may exclude a brand name medicine and require you to pay the entire cost of a (brand name) medicine when there’s a generic equivalent.  This is not a new concept, but it’s one that’s being deployed more often and more effectively by insurers with a greater need to control medical spending.

Pre-certification for tests, treatments and specialist doctor visits are also tried and true cost containment methods that are seeing renewed interest among carriers offering ACA-compliant plans.  Sending a patient for ten physical therapy visits first, before approving a costly MRI, specialist consultation and surgery can be a hassle for someone that’s endured the continuous agony of a pinched nerve, but it’s the reality of cost control in new plans in much the same way it was a reality for HMO patients a decade ago.

It’s always been important to know your plan and your provider network before buying, and to use it properly after purchase.  J.W. Terrill’s fee-for-service Private Client program starts with an analysis of current coverage and compares it against available alternatives in the broader market (including federally subsidized HealthCare.gov exchange plans).  Our post-placement education and dialogue is ongoing, personal and gives clients the perspective they need to make smart decisions on plan utilization.  Your insurance policy is a hedge against catastrophic and sometimes life-threatening risks; it shouldn’t be a quick, price-based decision followed by months or years of frustrating discovery.

Please call me when you have questions on new ACA plans, carrier cost containment methods or anything related to individual benefits.

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About Kevin Guss

Kevin J. Guss is a Consultant with our Private Client Benefit Services, specializing in providing individual health coverage (on and off-exchange), Medicare supplements, life, LTC and disability insurance to clients of J.W. Terrill and strategic partners. With more than 22 years of industry experience, Kevin counts many retired professional athletes, celebrities, business leaders and prominent members of the community among his clients. He has a Group Benefits Associate designation from the Wharton School of the University of Pennsylvania, a Past President of St Louis Association of Health Underwriters and a current board member of the MO Association of Health Underwriters.

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