Hidden Plan Changes

Hidden Plan Changes

Premium rate increases for small businesses have leveled off to an extent for many of our clients.  While it’s always welcome to have lower rates, some of that comes at a price. Beyond just raising the deductible, carriers are finding less obvious ways to save money or transfer risk.

The plans we have now differ in many ways to the plans we had a few years ago. There are the standard ways of cutting costs, higher deductibles and higher co-pays but what about the “hidden” changes that aren’t so apparent?

More Network Driven plans: Patients used to be able to see just about anyone for care.  Now there are more HMO, EPO and PPO networks and these networks are becoming smaller. Some services may require preauthorization.  The use of designated Primary Care Physicians and specialist referrals are also coming back.

Reduced or Eliminated Non-Network Benefits: Most people focus on the ‘in-network’ schedule, but out of network users now face higher deductibles, higher coinsurance and higher out of pocket limits. Carriers are also limiting their reimbursements to non-participating providers.

Fewer services covered for a co-pay. In the past a co-pay covered most of the services you received at the doctor’s office. Now many times labs, x-rays, and minor procedures fall under the deductible instead. That goes for preventative care too. If you visit your doctor for a physical, and mention your elbow hurts, they may charge you for a ‘sick’ visit.

Prescriptions: To help control rising Rx costs, plans are using:

  • narrower formularies
  • separate deductibles for Rx,
  • eliminating ‘dispense as written’,
  • maintenance medicine filled through mail order, instead of retail pharmacy,
  • network pharmacies,
  • prior authorization, quantity limits, step therapy,
  • tier adjustments (ex: moving a drug from tier 3 to 4)
  • mandatory generics.

This list isn’t exhaustive.  Your particular plan may or may not use these cost containment measures but we feel it’s important for our clients to be aware of the trend.

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