Health Insurance Navigator

By Lisa Zamosky

Last month, I wrote about health insurance exchanges – marketplaces where consumers who don’t get insurance at work will shop for and buy health insurance plans. Each state must have an exchange up and running by October 2013 as a requirement of the Affordable Care Act.

In response to my previous blog, readers posted questions wanting to know specifics about what they’ll find when they log on to shop for a health plan.

I spoke with Carrie McLean, consumer specialist with online insurance broker eHealthInsurance.com, to offer readers insight. eHealthInsurance is an existing private health insurance exchange and a good example of what states are working now to develop.

Maggie’s Question

The first question came from a reader named Maggie, who asked:

I have rheumatoid arthritis and receive Remicade infusions every six weeks. Will we be able to check procedure codes on the health insurance websites so we will be able to make our decision based on exactly what we need?

Exactly how the exchanges will work will vary by state, and because they are still under development many outstanding questions exist about how they’ll operate, McLean says.

Here’s what we do know: In an effort to simplify the shopping process, the law requires all plans to use the same standardized summary of benefits, which outline the key features of the plan and the benefits it covers – things like cost-sharing and limits placed on coverage.

The summary will also include a glossary of common health insurance terms to eliminate confusion. And coverage examples that illustrate how a particular policy will cover care for common scenarios, such as treatment for breast cancer, will be provided as well. Here’s an example of the format insurers will need to use and the type of information included.

However, whether or not a specific billed procedure is covered will ultimately be determined by its medical necessity.  “If it’s medically necessary, your infusions should still be covered. But keep in mind that plans available through the exchanges may vary in how much you are required to contribute out-of-pocket towards the cost of the procedure,” McClean says.

Also, the process by which particular medications are authorized (meaning your insurer agrees to pay for it) will vary among health plans.

So how do you confirm what services are included in a plan? Generally when it comes to figuring out whether the medications you need are covered, you want to review a plan’s formulary – the list of prescription drugs a policy pays for – before making your choice.  But it’s not clear yet if people will be able to look up coverage for specific drugs online. Some states may choose to make that information available on the exchange, while others won’t.

Let’s just say the exchange in Maggie’s state doesn’t offer that information online. In that case, the best way to get it will be the old fashioned way – either by picking up the phone to question the insurance company directly or by working with a licensed insurance agent who can help walk you through the process.

In Maggie’s case, it’s also important to point out another detail. Unlike most drugs, Remicade is typically administered by a nurse in a doctor’s office. “It’s not a pill you pick up from the pharmacy,” McLean says. For that reason, this particular medication (and others administered in a similar way) may be covered under a plan’s medical benefit, rather than under its prescription drug benefit.

Bill’s Question

Another reader, named Bill, asked the following question about exchanges:

Will the Health Insurance websites have information on the financial health of the company offering the insurance? Will we know how satisfied customers of that company were in the past?

According to McLean, it depends, again, on what each state decides to include in its exchange. Some state officials have said they want to make buying health insurance on the exchange as easy as buying a product on Amazon. So it’s certainly possible that customer reviews could be included, as could A.M. Best ratings, which specifically address the financial stability of an insurance company, McLean says.

More Exchange Information

Want to see where your state is in the process of developing its exchange? You can click on a map of the U.S. at the Commonwealth Fund to find out.

Ask your questions: Is there anything specific about health insurance exchanges or other aspects of the Affordable Care Act you want to know more about? Post your question in the comments section and I’ll do my best to answer.