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All Contents © 2017The Kiplinger Washington Editors
No matter how you get your insurance -- through your employer, from a state exchange, from an agent or directly from an insurance company -- you’re paying a bigger share of your health-care costs than you used to. Higher premiums are only part of the picture. Deductibles are rising, provider networks are shrinking, and insurers have been switching from fixed-dollar co-payments to coinsurance, based on a percentage of the cost of care.
Your out-of-pocket costs could rise significantly unless you learn some key strategies to become a better health care shopper. The following moves can help you save hundreds or even thousands of dollars.
By Kimberly Lankford, Contributing Editor
| Updated January 2015
Many insurers are shrinking their networks and including fewer doctors and hospitals. "The most expensive health care mistake you can make is to go out of your health plan’s network," says Jackie Aube, a senior vice-president of Cigna. The cost difference can be huge. Preferred provider organizations (PPOs) usually let you use out-of-network doctors but charge higher co-payments or coinsurance rates -- say, 50% for out-of-network care compared with 10% for in-network services. If your plan is a health maintenance organization (HMO), you may not have coverage at all for out-of-network providers except in an emergency.
The out-of-network base price may also be higher because the network’s providers agree to the insurer’s negotiated rate, but outside providers can charge more. You may also have a higher deductible for out-of-network care and a higher annual limit on your out-of-pocket expenses.
Before you visit a doctor or have a procedure, ask both your insurer and the providers if they’re included in your plan’s network. If you’re having surgery, check on the surgeon, anesthesiologist and facility.
Your health plan may provide extra incentives for you to use certain in-network providers or facilities. The UnitedHealth Premium designation program, for example, recognizes physicians that meet guidelines for providing high-quality, cost-efficient care, and you may pay lower co-payments or coinsurance rates if you use those doctors. Most health plans’ search tools can help you find providers who participate in these special programs.
Different facilities charge vastly different prices for x-rays and tests. The average outpatient hospital cost for MRIs and CAT scans is $1,384 to $1,668, says Aube, but the average radiology center costs $445 to $725. And there can be a huge range between the highest and lowest cost in your area. For example, among all facilities within 25 miles of New York, the cost of a knee MRI ranges from $238 at a free-standing radiology facility to $2,191 at a local hospital, says Victoria Bogatyrenko, vice-president for innovation at United Healthcare. Most insurers have tools to help you compare the costs of x-rays and tests at different types of facilities in your area.
Your doctor may work at several hospitals or outpatient surgery centers. While the surgeon’s charge will be the same, "the hospital’s fees can vary by thousands of dollars," says Aube. The cost may be even less at an outpatient surgery center, even though the same doctor is performing the procedure. For example, the average cost nationwide for a colonoscopy, GI endoscopy or arthroscopy in a hospital is $2,548, but the average cost at an outpatient surgery center is $959, she says. Make sure the facility you choose is in your insurer’s network.
Sometimes you can’t avoid a trip to the emergency room. But you may be able to go to a much less expensive urgent care center or convenience care clinic for some types of care. Visit an urgent care center for conditions such as minor cuts, burns and sprains, fever and flu symptoms, joint or lower back pain, and urinary tract infections, says Aube. You may pay even less at a convenience care clinic at a supermarket, pharmacy or other retail store, where a clinician can treat you for sinus infections, rashes, earaches, minor burns and other routine medical conditions, she says. The cost varies by type of facility: The average cost nationwide of an emergency room visit is $1,553, compared with $135 for an urgent care center and $58 for a convenience care clinic. Find out ahead of time which nearby urgent care and convenience care clinics are included in your insurer’s network.
Many health plans now offer 24-hour help lines staffed by doctors or nurses who can treat you by phone or online video chat. You can use this service for nonemergency conditions, such as cold and flu symptoms, nausea and vomiting, sore throat, earache, and sinus pain. A doctor will prescribe medications, if appropriate. The average telehealth consultation costs $40 to $50.
Generic drugs can cost as much as 80% less than their brand-name alternatives, says Aube. The lower list price makes a huge difference when you’re in the plan’s deductible period and paying the full price out of your pocket. And the coinsurance rates are usually lower, too -- often 10% to 15% of the cost for generics, 25% for preferred brand-name drugs, and 50% for nonpreferred brand-name drugs.
Some plans no longer cover certain brand-name drugs. For example, one popular health plan doesn’t cover Lipitor, which costs $180.75 for a 30-day supply of 10 mg tablets. But the generic equivalent, atorvastatin calcium, would cost $13.92 under the same plan, says Jim Yocum, executive vice-president of DRX, which provides Web-based prescription-drug comparison services to health plans and employers. You may also get a good deal on generics at certain stores, such as Walmart and Target, which charge as little as $4 for a 30-day supply of certain drugs or $10 for a 90-day supply.
The patents for several popular brand-name drugs -- Celebrex, Copaxone, Nexium, Actonel and Exforge -- are scheduled to expire soon, which will open the door for drug companies to manufacture generic alternatives. "It takes some time after patents expire for manufacturers of generics to receive approval from the U.S. Food and Drug Administration, make the drug and get supplies on drugstore shelves. Litigation can also delay expected patent expiration dates," says Yocum. You can look into generic alternatives now for Cymbalta, Maxalt, Maxalt MPT, Micardis, Micardis HCT, Twynsta and Xeloda, whose patents expired recently and for which generics are on the market, says Yocum. Most insurers have Web tools or apps to help you look up generic alternatives to your drugs.
Some brand-name drugs don’t have a generic equivalent but may have a "therapeutic alternative." That means a medicine that is in the same class of drugs but is chemically a little different. For example, Diovan is a blood-pressure drug with no direct generic substitute. In one popular plan, the monthly cost for a 30-day supply of 80 mg tablets is $149.66. But you could spend $1 per month for a comparable dose of iosartan potassium, or $2 per month for irbesartan, or $20 for a monthly supply of Benicar, says Yocum. Ask your doctor about any switch that isn’t a direct generic substitution.
More health plans are introducing preferred pharmacies, which cost even less than regular in-network pharmacies. For example, the Humana Walmart Rx plan for Medicare Part D charges a $1 co-payment for a 30-day supply of certain generic drugs purchased at Walmart or Sam’s Club (or a $0 co-payment through RightSource mail order), but the plan charges a $10 co-payment for the same drugs purchased at a nonpreferred network retail pharmacy. For pricier “Tier 4” preferred brand-name drugs (there are a total of five pricing tiers), you’d pay 39% coinsurance through Walmart, Sam’s Club and RightSource but 50% coinsurance at nonpreferred network pharmacies.
Mail-order pharmacies may provide a three-month supply of drugs for the same price as a one-month supply at a local pharmacy. Some plans require you to use mail order for maintenance drugs.
Ask your doctor if you can save money by cutting your pills. Your physician will have to write a new prescription for twice the strength and half the quantity, noting your intent to split the tablets, says United Healthcare’s Bogatyrenko.
Many health plans are adding new hurdles that you must clear before you can get certain medications. For example, you might have to try step therapy (which requires you to try other medications first, if possible) or seek prior authorization (the insurer asks your doctor a detailed list of questions about your condition and your treatment before it will cover the drug). Understand the rules for getting your drugs covered, and get your doctor involved to help explain to the insurer why you need the medication or to file an appeal if it is denied.
You can no longer use tax-free money from a flexible spending account or health savings account for over-the-counter drugs without a prescription (except insulin). To get reimbursed from your FSA or HSA, ask your doctor for a prescription for any medications you use regularly, such as pain relievers, allergy medications, anti-fungals and cough-and-cold medicines, says Jody Dietel, of WageWorks, which administers FSAs for employers.
The Affordable Care Act requires all insurers to provide several kinds of preventive care without any cost-sharing from you, regardless of your deductible. Depending on your age, this rule may apply to blood-pressure, diabetes and cholesterol tests, mammograms and colonoscopies, flu shots, routine vaccines, well-baby and well-child visits, and other preventive services (see the preventive-care page at Healthcare.gov for details).
The cost-free preventive care rule applies only to in-network services (it’s not unusual for an anesthesiologist involved in a colonoscopy to be out-of-network, for example), and you may be charged extra if something comes up in the test that requires more investigation. Ask if all of the providers involved in a procedure are in your insurer’s network. See Loopholes in Free Preventive Health Care for details.
Medicare beneficiaries can also get many preventive benefits without co-payments or deductibles. The list includes mammograms, screenings for cervical and colorectal cancer, flu shots, pneumonia shots, and an annual wellness visit and personalized prevention plan. See Medicare's Preventive & Screening Services for a full list.
Many employers who offered wellness benefits that weren’t worth the effort have been beefing up their incentives recently. More than one-fourth of the large employers surveyed by the Kaiser Family Foundation offer gift cards, travel, merchandise or cash to workers who participate in wellness programs. The rewards can be substantial -- large employers surveyed by the National Business Group on Health added an average of $350 to employees’ health savings accounts, or $500 to health reimbursement accounts, for participating in a wellness program.
You may get extra cash or discounts on your premiums for taking a health-risk assessment or participating in a tobacco-cessation program. Or your employer may offer free weight-loss or stress-reduction programs. More than half the employers surveyed by the Kaiser Family Foundation offer special disease-management programs for diabetes, asthma, obesity or hypertension. Such programs may provide incentives for you to take your medications, visit your doctor and have regular tests.
If you have a high-deductible plan, make sure you’re getting credit toward the deductible for all of your care. Even if you’re paying from your own pocket during the deductible period, file the claim so that you’ll get the rate the insurer negotiated with the provider. Check your explanation of benefits to make sure you received credit toward meeting your deductible and your annual maximum out-of-pocket spending limit. And time your procedures carefully -- you may want to schedule them near the end of the year, after you’ve met your deductible, rather than in the new year, when the deductible resets.
If your health insurance policy has a deductible of at least $1,250 for individual coverage or $2,500 for families in 2014, you may be eligible to open a health savings account. An HSA lets you set aside tax-deductible money (or pretax money through an employer) that you can use tax-free in any year to pay your deductible and other out-of-pocket medical expenses. In 2014, you can contribute up to $3,300 to an HSA for individual coverage or up to $6,550 for families (plus another $1,000 if you are 55 or older anytime during the year). For more information, see FAQs About Health Savings Accounts.
You may be able to collect extra money from your employer if you sign up for an HSA. Some match your contributions, but others seed your account just for signing up. It isn’t unusual for employers to contribute $500 for single plans and $1,000 for family plans, says Jeff Munn, of Fidelity, which administers HSAs for employers. Your employer may contribute even more to your account if you participate in a wellness program or take a health-risk assessment.
Because HSAs do not have a use-it-or-lose-it rule, you can keep the money growing in the account for the future and use it tax-free to pay for many medical expenses down the road, even in retirement. You can’t contribute to an HSA after you sign up for Medicare, but you can still use the money for, say, co-payments, deductibles, prescription drugs (including over-the-counter drugs with a prescription), vision and dental care, and a portion of your long-term-care premiums (the amount is based on your age). You can also use the money tax-free to pay your for Medicare Part B, Part D or Medicare Advantage premiums (but not for medigap).
If you use your HSA to pay out-of-pocket medical bills right away, look for an administrator with low fees, low minimum requirements, and maybe a debit card that makes it easy to use the money at the doctor’s office. If you use other cash for current medical expenses and keep the money growing in your HSA for longer-term costs, look for an administrator that offers good investment choices (many let you invest in mutual funds or sometimes even stocks), and see if you can minimize fees by maintaining a minimum balance in the account. Compare HSA administrators’ investing options and fees at www.hsasearch.com. See Contributing to a Health Savings Account in 2014 for more information.
If you don’t have an HSA-eligible high-deductible health insurance policy, contribute to a flexible spending account, if your employer offers one. You can contribute up to $2,500 to an FSA in 2014, and the money in an FSA escapes federal, Social Security and Medicare taxes (and in most cases, state and local income taxes, too). You can use these tax-free funds to pay out-of-pocket medical expenses throughout the year, and many employers now let you carry over $500 in FSA money from one year to the next. See Navigating New Rules for Flexible Spending Accounts for details.
If your modified adjusted gross income is less than 400% of the federal poverty level ($46,680 if you’re single or $62,920 for a couple), you can qualify for a government subsidy to help pay your premiums if you buy coverage on your state health insurance exchange. If your income is below 250% of the federal poverty level ($29,175 if you’re single or $39,325 for a couple), you can qualify for a cost-saving subsidy that reduces co-payments and other out-of-pocket expenses (but only if you buy a “silver” insurance plan). See Calculating the Health Insurance Subsidy for more information.
Notify the exchange if your income changes during the year. You can qualify for a bigger subsidy if your income drops or, if your income rises, you’ll avoid a surprise at tax time. Be careful about moves that could boost your income above the cut-off for the subsidy, such as converting a traditional IRA to a Roth or withdrawing money from a traditional IRA or 401(k). See Beware Pitfalls of Health Care Subsidy for more information.
Open enrollment for individual insurance is closed for 2014, whether you buy coverage on the exchanges or from an insurer (it re-opens on November 15, 2014, for 2015 coverage). But you may qualify for a special enrollment period if you leave your job or retire and lose your employer’s coverage (even if you qualify for COBRA), or if you have such life-changing events as getting married or divorced, having a baby, or moving to a new state. See the special enrollment period information at Healthcare.gov for details. If you retire in the middle of the year and your income drops, see if you qualify for a subsidy on your state exchange. Your full year’s income -- how much you earned so far this year as well as your estimate for your income for the rest of the year -- will be used to calculate whether you qualify for a subsidy.
Always get an itemized bill when you have a hospital stay or major procedure -- and question unexpected charges. Then match your bill with your explanation of benefits. Coverage may be denied if the procedure wasn’t coded properly, says Pat Pane, a medical claims specialist in Wilmington, N.C. You can find a medical claims expert at www.claims.org.
If you’re still in the deductible period, see if you can get a discount for paying cash. Make sure you’re getting the insurer’s negotiated rate and submit the claim yourself so that it counts toward your deductible.
Many insurers have improved their health care shopping tools over the past few years, using the insurer’s negotiated rates with providers in your area to show how much you’ll pay under your policy. Aetna’s Member Payment Estimator, for example, shows up to ten cost estimates for a procedure in your area, including a variety of options (stand-alone centers, hospitals, convenience-care clinics, ERs). You can also compare prices for your drugs at several pharmacies in the area, search for lower-cost medications, and find in-network providers.
Some employers and insurers even offer alerts to let you know when the price of your drug has dropped, if a generic alternative becomes available, or if you could save money by getting x-rays at a stand-alone facility, says Douglas Ghertner, president and CEO of ChangeHealthcare, which provides health care shopping tools to employers and insurers.
As soon as you get your policy, see which nearby hospitals and urgent care centers are covered as in-network providers.
To avoid surprises, find out about any special requirements for receiving emergency care.
Some stores, such as Walmart and Target, charge as little as $4 for a 30-day supply of some drugs or $10 for a 90-day supply, while some insurance companies charge a $10 co-payment for a 30-day supply. “Most generic medications cost less if you don’t use your insurance,” says David Belk, a physician in the San Francisco Bay area who lists drug prices and strategies for saving money on medical expenses at truecostofhealthcare.org. Belk especially likes Costco because it has an even longer list of generic drug deals.
Go to the National Council on Aging’s Benefits Checkup site (benefitscheckup.org) and anonymously input basic information about your income, assets, medical conditions and drugs.
You’ll see whether you qualify for any special programs to help with drug costs, such as drug manufacturers’ patient-assistance programs for low-income patients.
Consider scheduling procedures near the end of the plan year, after you’ve met your deductible, rather than waiting until the new year, when your deductible resets. And don’t wait until the last minute to schedule appointments; other health care consumers will be doing the same thing.
If you have an HSA-eligible health insurance policy on December 1, you can make the full contribution for the year, even if you’ve had the plan for only a short time. But if you didn’t have an HSA-eligible policy for the full year, you must keep it for the entire following calendar year or pay a penalty, says Todd Berkley, president of HSA Consulting Services. Say you sign up for an HSA-eligible policy on July 1 and contribute the full year’s amount. If you drop the policy the following year, you will have to pay income tax and a 10% penalty on the difference between the amount you contributed and the amount you would have been eligible to contribute based on the number of months you had an HSA-eligible policy.
Even though you can’t contribute to an HSA after you sign up for Medicare, you may be able to delay Medicare enrollment past age 65 and keep adding to an HSA instead—which could be a good strategy if you’re still working and your employer adds money to your account. Medicare Part A is free, so weigh your options to see which is a better deal. Delaying Medicare enrollment past 65 may not be an option if you work for a company with fewer than 20 employees or if you’re already receiving Social Security benefits.
If you have an HSA-eligible policy, you can roll money over from a traditional IRA to the HSA so you can avoid a tax bill when you withdraw money for medical expenses. You can make the tax-free rollover only once in your lifetime, up to the annual HSA contribution limit, minus any contributions you’ve already made for the year. You must be enrolled in an HSA-eligible policy for 12 months after making the transfer to avoid penalties.
The use-it-or-lose-it rule of flexible spending accounts used to be one of the biggest downsides to saving in these plans. If you didn’t use all of the money you set aside for eligible medical expenses by the end of the year, you’d lose it. But new rules permit employers to amend their plans to allow employees to roll over up to $500 in the account from one year to the next. Employers aren’t required to make the change, but a survey by Visa and WageWorks (which administers FSAs for employers) found that 53% of employers plan to offer an FSA with a carryover in 2014.
If your income is below 250% of the federal poverty level ($29,175 if you’re single or $39,325 for a couple in 2014), you can also qualify for a cost-sharing subsidy that reduces co-payments and other out-of-pocket expenses—but only if you buy a mid-level, silver insurance plan on your state exchange. With this extra subsidy, the silver plan may be a better deal than a bronze plan.
Notify your state health insurance exchange if your income changes. You can get a bigger subsidy if your income drops or avoid a surprise tax bill if your income goes up. If you’re close to the cutoff, make contributions to your 401(k) or HSA to reduce income used to calculate the subsidy.
Don’t unintentionally boost your income above the cutoff for the subsidy by, say, converting a traditional IRA to a Roth or withdrawing money from a traditional IRA or 401(k).
If you retire in the middle of the year and your income drops, you may qualify for a subsidy even if you earned too much while working. The subsidy is based on your full year’s income, including the amount you earned so far this year as well as your estimate for the rest of the year. Go to your state’s exchange (find links at healthcare.gov) for subsidy calculators.
If you are self-employed and not eligible for health coverage offered by an employer or spouse’s employer, your premiums are tax-deductible on your income tax return (as long as they don’t exceed your self-employed income).
If you buy health insurance on your own, you can switch policies when open-enrollment season for 2015 coverage starts on November 15. Most employer plans also have open-enrollment season in the fall. Compare premiums and out-of-pocket costs for the medicines you take and your typical health care services, and compare maximum out-of-pocket expenses in case you have a major health issue, says Michael Malasnik, a health insurance broker in Avondale, Ariz. Make sure your doctors are still in the plan’s network.
The federal law known as COBRA lets you keep your employer’s coverage for up to 18 months after you leave your job. You’ll usually pay much more for COBRA than you did for coverage while an employee; employers typically pay about 70% of the cost of coverage for employees but contribute nothing to COBRA. Compare the cost of COBRA with the cost of buying a policy on your own. If you buy a new policy on your state exchange and your income is low enough, you may qualify for a subsidy to help with premiums.
If you don’t qualify for a subsidy, look for coverage both on and off the exchanges for more options. UnitedHealthcare, for example, sold policies on only 12 state exchanges this year but sold policies off the exchanges in 25 states. Policies sold off the exchanges must meet most of the same requirements as those sold on the exchanges, including coverage for 10 essential health benefits, but they may have different premiums and provider networks. You can buy an off-exchange policy directly from an insurer, through an agent or through a Web site, such as eHealthInsurance.com.
Adult children can stay on most parents’ policies until they turn 26, whether or not they live at home or are full-time students. You may not have to pay extra for a policy that covers an adult kid if you’re already insuring other siblings. But if you do have to pay more, or if your child lives in another city that isn’t covered by your plan’s in-network providers, it might be less expensive for him or her to buy a separate policy. That’s especially true if you don’t claim your child as a dependent on your tax return and he or she qualifies for a subsidy.
If coverage for a drug you need is denied by your insurer or you want to go out of network for a special procedure, find out about your insurer’s appeals process. If in-network providers don’t offer similar specialized procedures, then the insurer may cover the out-of-network doctor at in-network rates. You may be able to get help from your state insurance department (go to naic.org for links).
Most people have no idea how much health care costs, and the same health care service can cost many times more than the least-expensive option, depending on where you receive care. You can look up fair prices in your area at Healthcare Bluebook, which calculates prices using a nationwide database of medical payments. If you’ve been quoted a much higher price, ask why. “Most doctors have choices about where they order your imaging, where they do your surgery and where you do the labs,” says Rice. “Discuss the quality and price difference for your choices with your doctor.”
Many insurers and employers have tools that help you compare prices for your medications, showing brand-name versions, generics and therapeutic alternatives.
They also offer smartphone apps to look up the lowest-cost pharmacies before you leave the doctor’s office.
Some employers and insurers send out alerts to let you know when the price of your drug has dropped, if a generic alternative becomes available or if you could save money by getting x-rays at a stand-alone facility, says Douglas Ghertner, president and CEO of Change Healthcare, which provides shopping tools to employers and insurers. This is the second in a series on navigating the new health care marketplace.
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