5 health plan barriers – and how to overcome them

August 28, 2019

It’s a sadly familiar scenario: You need treatment or medication for a health condition and *SURPRISE!*; in an attempt to save money, your health plan has thrown up barriers to prevent you from accessing the care you need, deserve and purchased.

My Patient Rights cares about making sure you get the care you need – when you need it – and works every day to help patients navigate and resolve health insurance barriers. Let’s start by understanding some common barriers to care.

Have you experienced any of these?

1. Step Therapy: Also known as “fail first,” step therapy allows health insurers to force patients to try a medication – usually a cheaper medication – and not have it work before being given access to the medication originally prescribed by their doctor. This practice puts patients at risk of getting sicker while they wait to get the medication their doctor deemed best for their condition. Consumers should check with their plan and doctor to see if step therapy applies to their condition and treatment and to determine if they are getting the care they need, when they need it!
2. High Deductible Plan: A high deductible plan is a health plan that requires patients to pay more out-of-pocket for health services before the insurance starts to pay for services (known as “reaching your deductible”). With a high deductible plan, patients may have to pay full price for needed treatments or tests, such as MRIs which can lead to patients not being able to afford the treatment or test at all, delays in care and serious financial difficulties. While a monthly premium may be lower on plans with high deductibles, consumers should consider the trade-offs before signing up.
3. Copay Accumulators: Some health plans implement a policy called the “copay accumulator,” coupon adjustment program or copay card program. When a patient uses a copayment card, the amount of money that the card is “worth” does not count toward the patient’s deductible or out-of-pocket maximum. For example, if a patient’s prescription costs $200, a co-payment card might only require the patient to pay $10 and the rest would be covered by the card. For patients with high deductible plans, the health plan would only recognize the $10 as part of a deductible payment, not the other $190 covered by the card. This can lead to big surprises and confusion for patients when calculating whether they have reached their deductible. Consumers should check with their health insurer to determine the plan’s copay accumulator policy before signing up for a co-pay card and high deductible health insurance plan.
4. Out-of-Network Charges or “Surprise Billing”: Health plans generally cover health service costs as long as patients use a provider within their plans’ network of doctors, labs, pharmacies, etc. Sometimes a patient may unknowingly see an out-of-network doctor during a visit to an in-network hospital, which can result in the health plan refusing to cover the bill or covering only a small portion. Before getting care, patients should check to see if a provider is in their plan’s network to avoid any additional unexpected charges. If you’re having trouble due to a surprise medical bill, you can submit a grievance through your health plan and/or your state’s regulatory agency.
5. Prior Authorization: Many health plans require they approve a patient’s treatment before they can receive the services. This is known as prior authorization. This process puts a health plan’s decision before that of the patient’s doctor and often delays care while patients wait for approval. Many states are beginning to enforce legislation that better streamlines this process so patients can access care when they need it, but in the meantime, patients and health care consumers should contact their health insurer to determine their prior-authorization policies and process and talk to their doctor about getting authorization expedited. If treatment is inappropriately denied through prior authorization, patients can submit an appeal with their insurer.

More information on how to file a complaint in each state can be found mypatientrights.org/file-a-complaint/.