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October 20, 2024
FIND THE BEST HEALTH INSURANCE PLAN When choosing health insurance, consider your specific healthcare needs. Be sure to make sure any proposed plans cover your prescriptions, any chronic conditions and provide mental health and substance abuse coverage.
Prescription drug coverage
Compare health insurance plans based on their formularies and costsharing structures. If you take prescription medications, be sure the plan covers them. The Affordable Care Act made it mandatory for individual and small group health plans effective from 2014 to cover prescription drug benefits as part of essential health benefits. Different health plans cover prescription drugs in various ways. Here are the main options: • Copays: The drug tier determines the amount your pay for prescriptions. • Coinsurance: You pay a share of the prescription cost with insurance paying the rest. • Deductibles: Some plans have combined deductibles that cover medical and prescription costs, while others have separate prescription deductibles. • Out-of-pocket maximum: Some plans cap total spending for in-network expenses for medical and prescription costs. Your health plan’s formulary is the list of drugs it covers. Insurers can create their formularies and make changes but must follow state and federal rules. The plans group drugs into tiers, with Tier 1 being the least costly and higher tiers covering the most expensive drugs. Top-tier drugs tend to be specialty drugs like injectables and biologics and typically require coinsurance payments. Under the Affordable Care Act, plans in the individual and small group markets must cover at least one drug in every U.S. Pharmacopeia category and class. Plans must cover the same number of drugs in each category as the essential health benefits benchmark plan selected by the state. The USP Medicare Model Guidelines require coverage for every general category of medications, but specific medications do not have to be covered by every plan. For example, while every plan must cover rapidacting insulin, it may designate a preferred brand. Similarly, the Affordable Care Act requires health plans to cover all types of FDA-approved contraception for women. Each plan can decide which specific contraception to cover within each type and may require costsharing for other versions or not cover them. Formularies often restrict medications through prior authorization, quality care dosing, and step therapy. Prior authorization means insurance approval before filling prescriptions, quality care dosing ensures FDArecommended quantity and dosage, and step therapy may require trying a less expensive medication first.
Chronic conditions
Most health plans cover chronic conditions or long-term health issues. It’s essential to know the details of any plan you consider. For example: • Job-based and self-purchased plans must cover pre-existing conditions due to the Affordable Care Act. • Plans starting in 2014 or later must cover essential health benefits for most long-term conditions. • Large company and self-funded plans may only cover some essential health benefits. • Some plans, like short-term health insurance, don’t cover pre-existing conditions or essential health benefits. Here are four factors to consider when selecting a plan: 1. Provider network: With a chronic condition, you’ll need regular care from specific medical providers, including specialists. Be sure your
preferred doctors and specialists are in-network and remember that provider networks can change. 2. Out-of-network coverage: If you need to see specialists outside your local area, understand how the plan’s provider networks and out-ofnetwork coverage works. 3. Covered medications: Different plans have different lists of covered drugs, so check if your medications are included and understand the cost tiers. 4. Total costs: Consider both the monthly premiums and the out-ofpocket costs for medical care. Most plans have a maximum out-of-pocket limits for in-network care, and you might be eligible for cost-sharing reductions based on your income.
Mental health and substance abuse coverage
Federal and Colorado laws mandate equal coverage for mental and behavioral health conditions and other medical conditions, known as “parity.” This means insurance plans cannot be more restrictive in providing mental health benefits than medical and surgical ones. Mental health parity laws require insurance plans to cover mental health and substance abuse treatment. It’s important to know what mental health benefits different plans provide. All plans must cover: • Counseling and therapy for behavioral health • Inpatient services for mental and behavioral health • Treatment for substance use disorder (substance abuse) Be sure you understand: • Your costs: Copays, coinsurance, deductibles, and out-of-pocket maximums are all part of your cost-sharing. • Treatment limits: There may be restrictions on the number of inpatient or outpatient visits covered. • Management tools: This could include requirements for pre-approval. • Choosing doctors: The plan will cover in-network providers and may also consider coverage for out-of-network providers and locations. • Coverage criteria: How the insurance company determines which treatments are medically necessary. “Mental Health” and “Behavioral Health” are terms sometimes used interchangeably but refer to different things. Mental health is about how a person feels and thinks, while behavioral health is a broader term that includes things that affect a person’s wellbeing, growth, and actions. This includes mental health conditions, substance use issues, eating habits, and outside factors like poverty, unstable housing, and trauma. Plans cover mental and behavioral health conditions without spending limits. Marketplace plans cannot refuse to cover you or charge you more because you have a pre-existing condition, such as mental health or substance use disorder.
Colorado health insurance resources
Connect for Health Colorado: This is the state’s marketplace/exchange. Residents can use Connect for Health Colorado to enroll in individual/ family health plans, receive income-based subsidies, and enroll in Health First Colorado. You can contact Connect for Health Colorado at 855-7526749 or visit connectforhealthco.com. Colorado Division of Insurance: Regulates the insurance industry in Colorado and assists consumers and businesses with insurance-related questions and concerns. Colorado Department of Health Policy and Financing (HCPF): Administers Medicaid (Health First Colorado), Child Health Plan Plus (CHP+), and other health care programs. Colorado Senior Health Care and Medicare Assistance: A service for Colorado Medicare beneficiaries and their caregivers, providing information and assistance with questions related to Medicare eligibility, enrollment, and claims.