Employer-Sponsored Health Insurance

Employer-Sponsored Health Insurance

If you have insurance or will be getting insurance through your employer in 2020, here’s where you can get all the information you need to be as prepared as possible. Year-to-year changes in employer plans can lead to surprising additional health care costs you may not be prepared for — as an example, read about what happened to Global Healthy Living Foundation Patient Advocate Lisa G., who has rheumatoid arthritis.

Look over each question below and familiarize yourself with the information before you select your health insurance plan.

How to Pick a Health Insurance Plan

There are a few important things to consider when choosing a health insurance plan that is right for you, especially if you are living with a chronic illness.

Find out the different types of private insurance available.  There are five types of common health insurance plans that you can choose from.

Find out what information you need before applying for insurance. Make sure you have all of this information before you start in order to make this process as fast as possible.

Find out if your medication is covered. Each health insurance plan has a list of covered drugs, known as a formulary. Read our step-by-step instructions on how to find out if your prescription is on a plan’s formulary.

Find out what out-of-pocket costs you’re responsible for. Your health insurance plan’s deductible, copayment, coinsurance, and out-of-pocket maximum determine how much you will end up paying for care. Learn more about each of these factors.

Learn about the various financial assistance programs available. There are several ways that you can find financial assistance to help cover your out-of-pocket costs.

Find out if you should expect a delay in getting your prescription. Find out if your medication requires prior authorization. If it does, your healthcare provider must fax a request to the insurance company for approval before you can pick it up from the pharmacy.

Avoid plans with a copay accumulator adjuster program. These programs, which can be found in some health insurance plans, do not allow copay cards to go towards your final deductible. Learn more about copay accumulator adjuster programs.

Have a complaint about your health insurance company? Learn more about the role of Insurance Commissioners and learn how to file a complaint.

Patient Real-Life Lesson: Lisa’s Story

Lisa G., Pennsylvania

Lisa G., from Pennsylvania, juggles a busy career, marriage, and raising two children all while living with rheumatoid arthritis. Having worked at the same company for more than 11 years, she had steady health insurance coverage that allowed her to access and maintain her prescribed therapies. Lisa preferred a high deductible plan because once she applied co-pay assistance toward her expensive RA medications, her deductible was reached early in the year. (Co-pay assistance is essentially like a coupon from your drug manufacturer that can help lower the cost of your medications, sometimes dramatically.)

However, last year Lisa’s employer reduced her health plan choices, offering only one high deductible plan for the upcoming calendar year. With careful reading of the fine print, Lisa discovered that this new health plan would not let her apply her co-pay assistance card to her deductible. Rather, once the value of the co-pay assistance was reached, then Lisa would be responsible for paying in full for her medications until her deductible was reached. Given the high cost of Lisa’s RA medications, being responsible for a high deductible all at once was financially out of reach. So she chose to select a PPO-style health plan, where her copays and premium are higher compared to her past plans but was more affordable than a lump sum deductible payment.

This choice costs Lisa and her family an estimated $2,400 more per year, and that’s before accounting for the copays owed at every doctor’s visit and other health care costs. If Lisa hadn’t diligently read her health plan options carefully, the surprise and enormously high deductible fee would have caught her completely by surprise.

Employer-Based Health Insurance FAQs

Can I negotiate with my employer about my health insurance coverage?

If you work for an employer that is considered small (2-100 employees), the carrier dictates the term of coverage so there is no ability to negotiate.  Conversely, if you work for a larger employer that is self-insured, there may be an opportunity for you to ask your Human Resources department or your employer to assist in modifying the terms of the health plan to provide assistance in paying for medications.

Also, ask if there is a coupon or pharmacy card available and how it can work. It is best to ask the pharmacy rather than the insurance carrier as the pharmacist fills a prescription by running the cost of the prescription through the insurance carrier software system.

My employer offers multiple plans. What do I need to know when I am comparing the plans that they offer?

1. Ask yourself: which plan will cover it and how will they cover it? What steps are necessary for accessing the medication I need or the doctor I see?

It is helpful to work backward and figure out which plan covers your medications and doctors.

  • There may be trade-offs when looking at your plan options, and you may need to decide by weighing the importance of these trade-offs. For example, if your specialist isn’t in-network on a plan, you may decide to pay out-of-pocket and have your prescription or specialty drugs covered because your relationship with your doctor may be a priority for you. If you need to make decisions about these trade-offs, think about what your priority is: Your prescription drugs? Your specialty doctor coverage? The general costs?

2. Estimate the costs of your care when comparing plan options.

Know the basics of plan designs and have an understanding of how their estimated annual cost of care compares to the premiums, out-of-pocket costs, deductibles, and in- versus out-of-network benefits that you would be responsible for. If you need help with this, you can always get in touch with your employer.

3. If you take specialty drugs, be aware of step therapy, non-medical switching, prior authorization, and copay accumulator card issues.

When reviewing carrier plans, keep this in mind. The plan details will specify if referrals or prior authorization are needed, the costs of specialists, and the network of providers. Detailed questions about certain treatments can be harder to find within the standard materials during open enrollment, but they should be included in the plan details (plan summary documents).

What are the three most important things to do if I have an employer-sponsored health insurance plan?

1. Review your employer’s health insurance plans every year and reevaluate your plan’s benefits.

Premiumsout-of-pocket costsdeductible, and in- versus out-of-network benefits can change.  It is important to be aware of these changes because it can drastically affect the cost of your care. Your employer should have custom benefit brochures highlighting plan changes every year.

2. Communication with HR or your employer prior to, during, and after signing up for a plan is critical.

There is no substitute for a helpful in-person enrollment session. Having someone in-person or on the phone is the best way to ask questions about your plan or choose a plan with confidence.

3. Dealing with insurance companies can be difficult and frustrating.

No matter how often you have difficulties, it is important to be persistent and self-advocate in order to ensure that you receive the coverage that you and your doctor believe is best for you. If you are choosing between plans or signed up for one and have questions about specific coverage items, go online to your insurer’s website or reach out to the customer service team. Be persistent in calling them, especially if they are not responding to your emails.

What should I ask my employer about health insurance?

1. How much will it cost me?

Review the premiumsout-of-pocket costsdeductible, and coinsurance of each plan offered and compare them. It is important to evaluate these costs in order to find the plan that works best for you.

2. What is covered?

If you regularly take prescription medications or specialty drugs, find out your copays and out-of-pocket costs for these drugs. These costs can differ depending on the plan, regardless of the premiums.

3. Who is in my network?

If you regularly see a physician prior to signing up for a new health insurance plan, check your plan options to see if your physician is in-network. If you have already signed up for an employer-sponsored plan, you will likely be able to search for in-network physicians or hospitals on your insurer’s site. Additionally, you can reach out of your physician with your insurance information, and often they can check for you.

How do I know if my prescription drug is covered?

Every health insurance plan has a list of covered drugs known as a formulary. Follow our step-by-step instructions on how to find out if your medication is on an insurance plan’s formulary.

I have a complaint about my health insurance company. What should I do?

Contact your HR department for help. If they are having trouble, it might be important to bring up contacting the insurance commissioner with them. While insurance commissioners’ duties may vary across states, their roles are generally the same: act as intermediary figures between individual consumers and insurance companies within the state. Learn more about Insurance Commissioners and how complaints are filed.


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