Friday, December 19, 2014

Consumers must be savvy to benefit from health reform

Never before had I been so excited for my health insurance to change. While I typically dread the hassle of dealing with a new policy with different in-network providers, this time I expected my coverage to improve. Thanks to the Affordable Care Act (ACA), the new plan would cover all government-approved preventive care without co-pays. This, I thought, would save me money.

Consumers must be savvy to benefit from health reform

By Erica Cohen

Never before had I been so excited for my health insurance to change. While I typically dread the hassle of dealing with a new policy with different in-network providers, this time I expected my coverage to improve. Thanks to the Affordable Care Act (ACA), the new plan would cover all government-approved preventive care without co-pays. This, I thought, would save me money.

I called my pharmacy benefits manager and said, “Sign me up!” The company is one of the largest pharmacy benefit management companies in the United States, so I expected its employees to know the relevant provisions of the ACA well.

After taking all of my information, a customer service representative informed me of the amount of the co-pay that would apply. “Impossible,” I replied, “ACA covers this as a preventive service.” It turned out that the representative was right, but it took me a lot of time and effort to get an accurate explanation of why.

The representative’s first explanation was, “Well I don’t think the preventive care section of ACA is in effect yet.” I informed her that it has, in fact, been in effect since August 1, 2012.  After a few minutes, I was presented with an alternate excuse: this particular service is not covered.

Unfortunately, she was dealing with a customer who has read up on ACA. I replied, “Yes it is. ACA applies to all approved preventive services.” She then suggested that it was not covered because it involved a drug that was not on my insurer’s formulary, which is a list of preferred medications.

The customer service representative decided to talk to a pharmacist, although it wasn’t clear why a pharmacist would have a better understanding of ACA than she. After a 10-minute wait – and a total of 65 minutes on the phone – she told me she had no answer and I would need to contact my insurer.

So, after taking a few deep breaths, I called my insurer and was informed that my plan was “grandfathered” and would not cover preventive health services until January 1, 2013. Grandfathered insurance plans are exempt from certain provisions of ACA. The insurance company representative assured me that this service would be covered with no co-pay beginning January 1. Why did it take so long to get the right answer?

It is difficult to understand how the average consumer can take advantage of ACA benefits if representatives of insurers and pharmacy benefit managers are unable to provide reliable information on how these provisions work. I consider myself fairly savvy on this topic. But what about other people? I have to imagine that most would have given up when the customer service representative gave the first excuse.

While the final explanation for my co-pay turned out to be correct, the first three were not. It should not take an hour and a half to find out why ACA’s preventive care provision does not apply to my plan.

Consumers must be aware of their rights and their insurance companies’ obligations. It is clear that we will need to advocate for ourselves rather than relying on the knowledge of the people who should (but often don’t) know the law.

About this blog

The Field Clinic reports and analyzes health care laws, government policies, and political trends that are transforming the care we receive and the way we pay for it. Read more about our panel of bloggers here.

This blog is produced in partnership with Kaiser Health News, 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. Portions of this blog may also be found on Inquirer.com and in the Inquirer's Sunday Health Section.

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Robert I. Field, Ph.D., J.D., M.P.H. Professor, School of Law & Drexel School of Public Health
Jeffrey Brenner, MD Founder of the Camden Coalition of Healthcare Providers, Medical Director of the Urban Health Institute at Cooper University Healthcare
Andy Carter President & CEO, The Hospital & Healthsystem Assoc. of Pa.
Robert B. Doherty Senior Vice President of Governmental Affairs & Public Policy American College of Physicians
David Grande, MD, MPA Assistant Professor of Medicine at the University of Pennsylvania
Tine Hansen-Turton Chief Strategy Officer of Public Health Management Corporation
Drew A. Harris, DPM, MPH Director of Health Policy Program at the Jefferson School of Population Health
Antoinette Kraus Director of the Pennsylvania Health Access Network
Laval Miller-Wilson Executive Director of the Pennsylvania Health Law Project
David B. Nash, MD, MBA Founding Dean of the Jefferson School of Population Health
Mark V. Pauly, Ph.D. Professor of Health Care Management, Business Economics and Public Policy at The Wharton School
Howard J. Peterson, MHA Managing Partner of TRG Healthcare, a national healthcare consulting firm
Donald Schwarz, MD, MPH Deputy Mayor for Health & Opportunity and Health Commissioner for the City of Philadelphia
Paula L. Stillman, MD, MBA Healthcare consultant with special expertise in population health and disease management
Elizabeth A. W. Williams Senior Vice President & Chief Communications Officer for Independence Blue Cross
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