Sunday, April 30, 2006

High Deductible Medical Plan Review

I have just finished the first four months of a High Deductible Medical Plan. Since there is always a lot of discussion around this type of plan, I thought I would share my thoughts with you

To give you some information, Dear Son is covered under a High Deductible Medical Plan via my ex-husband’s employer. There were two plan options to pick from: Option A-a medical plan with minimal benefits or Option B-a High Deductible Medical Plan with more benefits. We chose Option B. I should also tell you that despite all the handouts from the employer promoting this plan, once he was enrolled in the plan, it has been virtually impossible to get information; it’s hard to get information from the employer, the insurance company and just about the plan in general. I admit I don’t know much about these plans however I should tell you, that I probably have more experience than a lot of people with medical benefit plans, for reasons I won’t explain here. I should also tell you that my ex-husband helps out a lot with supporting Dear Son but the medical expenses of the last few years have left us both struggling.

Dear Son’s medical needs include: six seizure meds (he has intractable seizures and a VNS implanted), two GI meds, uses a thickener for liquids to prevent aspiration (he aspirates liquids when he drinks), has a feeding tube, wheelchair, AFO’s (leg braces) and is incontinent. He can not walk, sit up, roll over, talk, go to the bathroom, feed himself and his hands/arms do not work so he can not get himself a drink or hold a glass. He is dependent on me for all daily needs.

Here’s what I have learned and experienced so far:

• High Deductible Medical Plan-The concept sounded o.k. The plan was the employer and employee would both donate money into a Healthcare Savings Account, also known as an HSA. The money they would both donate would cover your “high deductible” and after that was met, the plan would pay 90%.

• Reality: Yes, the employer donates money however in his case, they don’t donate it all at once. The employer staggers the donation. Also, the employee is allowed to withdraw money up to the amount that he has contributed to date. If your expenses go over this amount, you can write yourself a check for the amount you coughed up when the money is available. Follow along and I’ll explain when I get to pharmacy, how this is a problem.

• Benefit-Durable Medical Equipment-The new limit is $2,000 a year. In his prior plans, there was not a limit for DME.

• Reality#1: Dear Son needs a new tilt wheelchair at a cost of approximately $10,000. The plan doesn’t come close to meeting his needs.

• Reality #2: Dear Son’s leg braces (AFO’s) cost approximately $2,200/year.

• Benefit-Private Duty Nursing-In the past, we have had Private Duty Nursing, up to $1,000 per month as a benefit.

• Reality-There is no coverage at all. Who can help me with Dear Son’s needs as they get more demanding?

• Pharmacy-This was by far my biggest headache to date. The materials state that you can use a mail order pharmacy to get a discount on the prescription drugs. They also give prescription drug calculator to figure out the costs and show you how much it would cost for a prescription. For example, if you want to look up a drug, you need to know the name, strength, and quantity per month.

Under the PPO plan, I paid $20 for a one month supply at a local retail pharmacy OR $20 for a “three” month’s supply via the mail order plan. This is how all of the mail order plans have worked in the last ten or more years that I have been using them. You pay a one month co-pay for a three month supply of medicine.

So, let’s illustrate what happened to me using one of Dear Son’s seizure drugs, Keppra as an example. When I did the prescription drug, estimator, I typed in Keppra, 500 mg, 120 pills and the cost was $355.53 for a “one” month supply at a “retail” pharmacy OR $253.90 via the mail order program.

So, what I thought would happen was that my cost would go from $20 to $253.90 with the mail order plan for a 3 month supply OR I would pay $355.53 for a 1 month supply at the local pharmacy.

• Reality: What really happens is that you pay for all three month’s worth of medicine. So the cost for this one medicine was really $830.24. What they don’t tell you in the brochure, is that with the new High Deductible Medical Plan, you pay for “three” months worth of meds at a “discounted” price.

To illustrate, in 2005, I paid $141.00 for three month’s worth of all nine medicines. In 2006, those same medicines cost, $3,193.07.

This was quite a surprise. I thought they were going to cost, $995.79 and they were really going to cost $3,193.07. My actual costs were actually a little higher due to some increases in the medicines. I also learned, that it was cheaper when you used the correct strength of a medicine. Let’s say you were using a 500 mg tablet but your doctor increased that amount over time and you were taking 1000 mg in the morning and 1500 mg in the evening. It would be cheaper to purchase 1000 mg tablets and then cut one of the pills for the 1500 mg.

Now, once I figured out how much these were going to cost, I had to go back and re-calculate all of the meds based on the amount of money that was going to be AVAILABLE in the plan.

What I ended up doing, was counting out pills for each of the medicines and staggering when I submitted them. Ped Neuro Doc also generously helped out by giving me samples of two of the most expensive drugs.

It also affected how the physician did his job. When Dear Son was having more seizures, we had to work together, to figure out which meds he could increase based on which ones I could afford. I don’t want to start getting in the way from how he practices medicine. I want him to recommend what is best for Dear Son, not have to second guess every medicine change based on this health plan.

What I learned:

1) If you can avoid the High Deductible Plan, do it. Pick any other plan, if you can.
2) Watch out for the pharmacy.
3) HAS’s really benefit the employer. Flexible Spending Accounts work much better but those are not an option under the High Deductible Medical Plans. The reason that I prefer FSA’s is because when you put money into your account, you can deduct the entire amount on the very first day of the plan. Let’s say, for example, you donate $2000 of your wages in an FSA that will be deducted in 26 pay periods. On January 20th, you have an bill come in and you owe $1800. With an FSA, you can pay $1800 out of your FSA on that day. With an HAS, you can only withdraw the amount that has been deposited in your plan.
4) The benefits are a LOT less, at least in my case.
5) This plan is better than no plan but it does not in any way that I could tell, benefit the employee or consumer. This is strictly, employer driven.

I should also mention that proponents of these plans say that the purpose of these plans or insurance in general, is to protect against catastrophe and yet I am not convinced that these plans do this at all. These plans are also very different than the PPOs we have had previously. This plan BARELY meets Dear Son’s needs. If it doesn’t meet his needs, then who exactly is this plan designed to cover? I mean, the plan has ZERO private duty nursing. Does that sound like a plan that will cover catastrophic illness? The plan has a $2000 limit on DME? Does that sound like a plan that will cover catastrophic illness? And what about pharmacy? In a catastrophic illness, chances are you will need drugs and a lot of them. They will be expensive, there won't be generics and you will need them now. So how, will this plan benefit these people? Yes, once the deductible is met, then you pay your portion until you hit the stop loss, but really, how do you pay for that if you are on disability due to a catastrophic illness and you are getting only 40 or 60% of your salary?

So, my question is, why should people choose this plan? How can we pay for all of these services? Yes, I do have a secondary medical plan that is helping with some of these expenses however THEY contacted me and told me I should consider Medicaid because it offers private duty nursing, wheelchairs and prescription drugs have no co-pays.

So, who is this plan designed for? Someone who doesn’t have a medical condition, or are we just trying to drive people to Medicaid?


Wrkinprogress said...

Before I got to the end of this post I was thinking Dear Son needs to be on Medicaid, for YOUR sake if not for his own. And yes, I wonder, too, if our insurers are out to drive us all away from them and on to Medicaid, IF we qualify! Our health plan changed this year, too -- and the drug plan is the worst part of it. Hard to take when we all know that health insurance companies, and especially the pharmaceutical industry, is making record profits.

{{{{{{{{{{Dream Mom}}}}}}}}}}}} Big hugs to you, hon. I wish I had a solution for you. Keep thinking about that foundation....


Mete said...

This reminded me so much of issues we faced this year. My employer added two HD plans and were PUSHING them. They kept saying how low the weekly premiums are, which sounds fine - as long as you and everyone in your family NEVER get sick. But with the thousands in deductibles, it gets to the point where you wonder why you even have health insurance in the first place?

They also changed our pharmacy plan so that we have to pay 25% of all monthly prescriptions up to a maximum. Again, they tried to make this sound like a GREAT deal - giving the example of taking one generic drug where the max is only $5. While my son is not as many as your Dear Son right now (only 3 seizure meds and 1 GI), I know he will be on others in the future, and almost NONE come in generics.

I hope your ex can change plans at the next open enrollment. The HDMPs are all about big companies. It's a ploy to save themselves money while giving the employees the illusion of saving money too.

Best of luck.

Anonymous said...

I'm sorry to hear about the trouble you're having with your plan. My husband and I own a small business,and offer both a standard plan and an HDMP w and HSA to my 25+employees. The HDMP and HSA actually costs us approx $200/month MORE per employee, but I encourage the plan because I believe in the economics of HDMPs and HSA's. It sounds to me like the plan your ex's compnay offers is the problem, not HDMP & HSA's in general. Ours offers 100% coverage after you meet the deductable, which in your case, with such high expenses, would be extreamly beneficial. Don't write off the concept becasue your ex-husband's company offers a poor plan.

Good luck to you.

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