New Calendar Year, New Health Insurance Year

Surprises That May Upset You When It Comes To Continuity of Care

Article ID: 645729

Released: 7-Jan-2016 6:00 PM EST

Source Newsroom: Pennsylvania Medical Society

Newswise — You’ve made it through 2015, and as you enter the New Year, a new health insurance year is starting as well.

What does that mean for you?

For many people, likely there’s not much to worry. But for some, there may be a few surprises along the health care highway, whether your company contracts for group coverage or you shop independently for your own insurance.

According to Scott Shapiro, MD, president of the Pennsylvania Medical Society and a practicing cardiologist with Abington Medical Specialists in Abington, with so many health insurance options available, inevitably someone’s going to hit a pothole. Those who are switching insurance products or insurers are more likely to do so, he says.

“What’s covered in one plan one year may be a little different in another plan the next year,” Dr. Shapiro says. “On occasion, we’ll see this when it comes to physician networks and medicines. There may even be a financial surprise for care that overlaps from one insurance year into the next.”

For example, says Dr. Shapiro, a physician may be included in a network under one plan, but maybe not in another.

“Even within the same health insurance company, a physician may be part of one insurance product, but not the next, particularly as more plans build narrow networks,” he says. “Patients who have been seeing a specific physician for years, and are happy with their physician, may find this discouraging, but those who are undergoing treatment shouldn’t have to worry.”

Dennis Olmstead, senior advisor, health economics and policy at the Pennsylvania Medical Society, explains that Pennsylvania Act 68 of 1998 and its accompanying regulations guide continuity of care for health plans in Pennsylvania. Among other things, it ensures that a plan enrollee may continue an ongoing course of treatment for up to 60 days from the date the enrollee is notified by the plan of the termination of a participating health care provider.

“Fortunately, there are safety mechanisms in place that requires insurers to allow patients undergoing treatments to remain with their physician, if they choose,” he says. “But, a patient who is not undergoing treatment might find that their physician is not included in their new insurance plan.”

Olmstead says those patients who shop for health insurance in the marketplace and switch between the “metal plans” such as going from a bronze plan to a gold plan could find themselves in this situation.

Formularies – or a list of medications an insurance plan covers – may also be different from one plan to the next.

Since most generics for common health issues seem to be included in the majority of formularies today, many patients likely do not need to worry about a change in plans or transitioning from one insurance year to the next. But, sometimes a drug is removed from one year to the next, or moved to a different tier in the formulary, and newer drugs may not have made it onto a formulary yet.

Nicole Davis, MD, president of the Pennsylvania Academy of Family Physicians and a practicing physician in Wyncote, recommends that patients find out if the drugs they use are included in a health plan and the tier level before they change health plans.

“The patient may have to make a few phone calls or visit a website to learn if certain drugs they use are on the new plan’s formulary,” says Dr. Davis. “Periodically, we’ll hear from patients that they were surprised that they had to suddenly pay more for a medication that previously was a lower out-of-pocket expense.”

Another insurance scenario that sometimes catches patients by surprise involves large deductibles and occurs as one year ends and another begins.

“Patients sometimes are surprised when they meet a large deductible in December, and then have care roll into the new year that they will need to pay the same large deductible in January,” says PAMED’s Olmstead. “It’s very possible to have two large deductibles due in back-to-back months in this scenario.”

Olmstead says that it isn’t always possible to plan when care is needed particularly when emergencies occur, but there are some treatments that can be.

Joanna Fisher, MD, president of the Pennsylvania Academy of Ophthalmology and a practicing ophthalmologist in Huntington Valley, agrees with Olmstead and points to a common procedure her specialty performs. “For example, if you know you have cataracts in both eyes and are planning to have both eyes fixed, work with your physician,” Dr. Fisher says. “You can likely schedule those in the same insurance year to avoid paying a large deductible in consecutive years.”

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This news release is brought to you by the Pennsylvania Health News Service Project, consisting of 21 Pennsylvania-based medical and specialty associations and societies. Members of PHNS include Pennsylvania Allergy & Asthma Association, Pennsylvania Dental Association, Pennsylvania Academy of Dermatology & Dermatologic Surgery, Pennsylvania Academy of Ophthalmology, Pennsylvania Academy of Otolaryngology, Pennsylvania Academy of Family Physicians, Pennsylvania American Congress of Obstetricians and Gynecologists, Pennsylvania Chapter of the American College of Cardiology, Pennsylvania Chapter of the American College of Emergency Physicians, Pennsylvania Chapter of the American College of Physicians, Pennsylvania Chapter of the American Academy of Pediatrics, Pennsylvania Medical Society Alliance, Pennsylvania Medical Society, Pennsylvania Neurosurgical Society, Pennsylvania Orthopaedic Society, Pennsylvania Psychiatric Society, Pennsylvania Society of Anesthesiologists, Pennsylvania Society of Gastroenterology, Pennsylvania Society of Oncology & Hematology, Robert H. Ivy Society of Plastic Surgeons, and Urological Association of Pennsylvania. Inquiries about PHNS can be directed to Chuck Moran via the Pennsylvania Medical Society at (717) 558-7820, cmoran@pamedsoc.org, or via Twitter @ChuckMoran7.


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