6 tips for choosing the best insurance plan on the Obamacare “exchanges”




The Obamacare, aka Health Care Reform, aka Affordable Care Act (ACA) “exchanges” are live.

And if you live in a state whose exchange didn’t get overwhelmed with traffic yesterday (I know Floridians and Californians had a lot of hiccups, but John says he had no problem in DC until last night when even Blue Cross’ Web site was inaccessible for a while), you may have always browsed through the various health insurance plans and found something to your liking.

The exchanges, as you know, are intended to provide a one-stop shop for people to peruse various plans from various companies in a unified format that makes it easier to comparison shop, and hopefully increases competition, and thus decreases the cost.  And in many cases, they’ve done just that.

John wrote last night about his initial experience using the DC exchange in order to search for better health insurance than he currently has.  In John’s case, his insurance is quite good except for its prescription drug coverage, which is downright awful.  And while that might not seem a problem when you’re younger, and not taking many prescription drugs, as you age you’re more likely to be on more drugs, and more expensive drugs.  At some point, the cost could easily become prohibitive.

So, here are a few tips I came up with to help John, and all of you, think through which health insurance plan on the ACA exchanges might best suit your needs.

obamacare, ACA, affordable care act, health care reform, exchanges

1. Prescription drug coverage

Different plans cover prescription drugs in different ways.  One plan might have you pay a percentage of the cost of the drug, while another might charge you a fixed amount per drug, depending on the category of drug (generic vs. brand name, and depending on whether they’re categorized by your plan as “preferred,” “non-preferred,” or “specialty” drugs.)

If there are prescription drugs you take regularly, you might want to find out exactly if, and by how much, your plan covers those drugs.  Here’s how.

You should be able to ask the insurance companies offering the plans you’re interested in to give you the link to each of their “formularies.” The formulary lists all of the drugs covered under your plan and should tell you what the copay or coinsurance is for each is. If they won’t give you a link to the formularies, ask to speak to one of the plan’s pharmacists. When you get the pharmacist, tell them what drugs you take, their strengths, and how many times a day you take them. The insurance company pharmacist should be able to tell you if those specific drugs are on formulary or not.

Be careful, though. Sometimes one strength of the med will be on formulary and another will not. Bizarre, but true.  And, as always, each plan in BCBS may have its OWN formulary. So you need to look at what drugs are available in the formulary for YOUR specific plan.

Also, even though a drug is on the formulary right now, it could be dropped at some time in the future. For example, Lipitor might be on the formulary at the moment. But if the insurance company gets a better deal from Zocor, they may drop Lipitor. Usually, that’s not a major problem, your doctor can switch you to another drug. However, sometimes they will drop a drug and NOT offer a replacement. And as John has learned with his asthma treatment, a specific very-expensive brand name drug tends to work for him, while others do not. If the drug is dropped from their formulary, the only way to continue taking it is to pay 100% of the cost out of your pocket, in his case nearly $300 per month for one drug.

Also, be sure to check the maximum copay.  A friend of mine recently got a prescription.  The drug would cost about $1700/month if he paid cash.  It was covered under his insurance, but the copay was $500.  So make sure you find out what your maximum copay could be for most situations: pharmacy, ER, specialist, primary care physician, etc.

2. Make sure all of your doctors, including specialists, take the specific plan you’re considering

It’s not enough to check whether your family doctor, or your asthma specialist, takes “Blue Cross Blue Shield.” You need to check if they take the specific Blue Cross plan that you’re considering buying.  For example, in John’s case, he’s preliminarily considering purchasing the BluePreferred Platinum plan, or the HealthyBlue Platinum plan.  He needs to ask all of his doctors if they take those specific plans. They might not.

Also, if you go to some health insurance companies’ Web sites and you search for a doctor by typing in their name, the main insurance company Web site may show that your doctor is in network, and he is. But if you go to the insurance company’s PPO or HMO subdivision, your doctor may no longer be listed because while they take Blue Cross’ PPO, they may not take Blue Cross’ HMO. That initial Web page makes the plan look like it takes a gazillion doctors, but when queried about a specific sub-plan the number of doctors in that plan may be low to none in your immediate area.

3. Make sure the insurance company has enough specialists for your specific plan

The issue is broader than just making sure you can keep your own specialist under a new plan.  You also need to make sure that the insurance company has enough specialists generally, so that you’re not waiting months to get an appointment.

Go to the insurance company’s Web site and take a look at the lists of doctors they have available for each specialty. If they only have five endocrinologists in-network, you may have to wait two months to get an appt with one. So make sure that you have several of each specialist type available. Also, be aware that some health plans don’t update their provider lists all that frequently. It’s good for them, makes them look like they have thousands of providers, when, in reality, they may have many fewer.

Several years ago, I needed to see a pulmonologist. There were around 15 listed in my plan. Yet only two were actually still enrolled in the plan. One had stopped practicing, except for hospital consults, and the other wasn’t accepting new patients. I had to call the insurance company several times, and fight to get them to authorize another pulmonologist – it wasn’t easy, and I’m an MD.

Also, be aware that even if there are a lot of providers listed, just being listed does NOT mean that they’re taking new patients. You’ll need to call the doctors to ask about that.

4. In-patient hospital coverage

John encountered similar uncertainty when comparing the plans’ hospital room coverage.  One plan charged him $150 per day for a hospital room, while the other charged 10% of the allowed benefit (meaning, the insurance company negotiates a lower price for the hospital stay, and you pay 10% of that).  But which is lower?  It depends on how long you’re in the hospital, what you’re in for, and which hospital you go to in which part of the country.

You can get an idea of the cost of a hospital room by calling a local hospital and asking what their room rate is. They’ll usually tell you, after you push them a bit, what the cost is for a semi-private room. That’s the “no-frills” room. Note that a bed in a telemetry unit will cost you much more, and an ICU bed even more than that (a LOT more). Most hospitals will try to get you in and out ASAP. Actually, as you’re being admitted, they’ll already be thinking about discharge planning. So, if you go in for, example, a gall bladder removal, they’ll get you out in under 3 days, unless there are complications. However, if you have a major catastrophic illness, you could be in for weeks or months, and it will cost a lot.

5. Emergency room costs

Also, emergency room charges can be HUGE, sometimes tens of thousands of dollars for an admission. Make sure you find out what, if anything, you need to pay for an ER visit and any requirements before you use ER. Sometimes, plans will require that you call your primary care physician before going to the ER, if it’s something that’s not major and life-threatening (e.g., if you’re having a heart attack, stroke, breathing difficulties, etc., you likely won’t need permission to go the ER). But they may want you to call your primary care physician for his approval for something like severe back pain.

John tells the story of a friend of his, back in the 1990s, who had shooting pains in his groin while traveling out of state. His friend was quite literally doubled over on the floor, in a fetal position, screaming so loudly that they had to stuff a towel in his mouth so that the neighbors wouldn’t think he was being murdered. Of course they rushed him to the emergency room, and since it was a holiday weekend, they couldn’t get hold of his doctor in order to get “permission” to go the ER.  That friend had a long drawn out battle with his insurance company because he didn’t pick up the phone and call them while doubled over on the floor screaming in agony as a searing pain was traversing his groin.

Also, be aware of another catch with ER coverage. Under some plans, if you go to the ER and you don’t like the treatment you’re getting, for example, you think they’re not doing a good job, you have a personality clash with the doctor, etc., and you leave against the medical advice of the ER staff, the insurance company may refuse to pay because you failed to complete treatment. In that case the WHOLE ER BILL CAN BECOME YOUR RESPONSIBILITY.

6. Extraneous coverage

Some plans will have very limited coverage or no coverage for things like: skilled nursing facilities, hospice, outpatient therapy, home care nursing, dental, vision, psychiatric benefits, etc. It’s a good idea to ask about those, too.

Also, if you ever plan on traveling abroad, find out what they do and don’t cover if you get sick in another country.  Often, as in John’s case, they don’t like to tell you in advance if they’ll cover a specific procedure (in his case, a retinal detachment while traveling in France).  What they might tell you, however, is that they cover “emergencies,” which still can help a lot (in John’s case, his insurance only covered emergencies, but a retinal detachment is an emergency, and for good measure he had his French doctor write a letter explaining the emergency to his insurance company (he was unable to travel), so in the end the insurance treated the surgery as “in network,” and had John pay 10% of the cost).

Also, ask about preventive care. Some plans will partially sponsor a gym membership (or will lower rates if you document that you use a gym regularly), help with smoking reduction, diet and exercise/nutrition counseling, weight loss, vaccinations, etc.

Some insurances will cover eye exams, glasses, chiropractor visits, while some don’t.  It would be a good idea to find out just how inclusive your plan is.

There are no guarantees, but this should help

None of this is a guarantee that you’ll find the perfect plan.  And sadly, even with the reforms under the Affordable Care Act, it might sometimes feel as if you still need an MD, or a law degree, in order to figure out the fine print in these various plans.  But at least I hope these tips walk you through a more efficient way of evaluating these plans – any plans, really, this isn’t just limited to the Obamacare exchanges – and hopefully you’ll end up with better coverage as a result.


Mark Thoma, MD, is a physician who did his residency in internal medicine. Mark has a long history of social activism, and was an early technogeek, and science junkie, after evolving through his nerd phase. Favorite quote: “The most exciting phrase to hear in science... is not 'Eureka!' (I found it!) but 'That's funny.'” - Isaac Asimov

Share This Post

© 2021 AMERICAblog Media, LLC. All rights reserved. · Entries RSS