Health-Insurance Changes for 2011

What differences can I expect to see in my health insurance for 2011 during my employer’s open-enrollment season this fall?

Employers will be making some changes to their health-insurance plans for 2011 because of health-care reform -- such as offering coverage to children up to age 26 -- and as a way to help control rising health-care costs. A recent survey of large companies by the National Business Group on Health found that employers estimate their health-care-benefit costs will increase by an average of 8.9% in 2011, compared with an average increase of 7% this year. These employers are continuing to boost premiums and co-payments, but they’re also beefing up programs that encourage employees to lower their medical expenses.

Here’s what to expect when your employer gives you health-insurance choices during open-enrollment season this fall -- and how to make the most of the changes:

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Higher premiums and co-pays. Sixty-three percent of the employers surveyed plan to increase the percentage that employees contribute to the premium (on average, employees contribute 17% of the premium for single coverage and 27% for family coverage). And 46% plan to raise out-of-pocket maximums. About 40% of employers also intend to increase in-network or out-of-network deductibles.

These large employers have already been boosting employees’ share of the premiums and co-payments over the past few years, and they realize that increasing employee costs cannot be their only solution -- especially because many workers have had stagnant wages and may have a spouse who lost a job, says Helen Darling, president of the National Business Group on Health.

If employers increase co-pays too much, the employees may not seek care they need, which could lead to greater medical expenses in the future. And the claims costs have a direct impact on these employers, who are self-insured and pay claims from their own money, using an insurance company only for administration (a common practice for many large companies). These employers are targeting some of their increases at areas that will help encourage employees to be more careful about costs -- such as increasing cost sharing for non-emergency care at an emergency room.

The solution: If you have a choice of several plans, factor your potential out-of-pocket costs into the equation rather than looking just at premiums. Evaluate the new rules for co-payments carefully when deciding which type of care to use throughout the year.

More high-deductible health plans and health savings accounts. Sixty-one percent of the employers surveyed said they plan to offer a consumer-directed health plan in 2011 (usually a high-deductible health plan combined with a health savings account), which helps lower health-care costs because it encourages employees to become better health-care shoppers. In fact, 20% of the employers plan to make the consumer-directed health plan the only choice. Those that are offering several options are steering employees toward the high-deductible plans by reducing premiums and often contributing money to the employees’ health savings accounts.

The solution: These extra incentives may make a high-deductible plan worthwhile, even if you aren’t in perfect health. Also, most high-deductible plans now cover preventive care without cost sharing before you reach the deductible. Look carefully at the high-deductible plan option this year and consider adding some of your own money to an HSA (if you’re eligible). Contributing to an HSA lowers your taxable income, and your money grows tax-deferred for the future and can be used tax-free for medical expenses in any year -- even after you switch to a new job. See my column for more information about HSAs.

Better deals for primary-care and wellness programs. Many employers intend to reduce or eliminate the co-pays for primary care and preventive care, which can help catch problems early and lower medical expenses in the long run. Employers have been experimenting with various forms of wellness benefits over the past few years, and most now give people bonuses for participating in wellness programs rather than penalizing them if they do not. "They like carrots more than sticks," says Darling. Forty-one percent of the employers are offering discounts for participation in wellness programs, and the average incentive to employees is $380; 22% of employers offered discounts on premiums for participating in tobacco-cessation programs.

The solution: Employers realized that they needed to provide workers with better incentives to sign up for wellness programs. So if participating in one seemed like a hassle in the past, it may be worth a second look this year. Also, get a list of free preventive-care services and make the most of them throughout the year.

Extra charges for brand-name drugs. Over the past few years, more employers have been charging varying levels of co-pays for different types of drugs. Sixty-three percent now have a three-tiered design for their prescription-drug coverage, charging the lowest co-pay for generic drugs, the middle rate for preferred brand-name drugs and the highest co-pay for other brand-name drugs.

People also have to jump through more hoops to get their drugs. Seventy-three percent of employers now require prior authorization before they will let you use certain drugs, and many are using step therapy, which requires doctors to try a lower-cost drug first before certain higher-cost drugs will be covered. Employers are also changing co-pays to encourage you to get your drugs from a cheaper source. For example, some will fully cover the cost of maintenance medications only if you use mail-order pharmacies. If you choose to get the medication at a local pharmacy instead, you pay the difference between the cost of mail order and the retail price.

The solution: If you take medications regularly, look carefully at how the drugs are covered and your potential out-of-pocket cost. Switching to generics, when possible, will always save you money, and the cost savings becomes even more pronounced if your employer charges a lower co-pay for the lowest-cost drug. Also reconsider where you buy your medications if your employer provides a higher level of coverage for mail-order pharmacies. And find out about any prior authorization or step-therapy requirements before using a new medication so you don’t get hit with surprise charges if you don’t follow the rules.