MEDICARE
NAVIGATING THE MEDICAL INSURANCE GAP T
he unfortunate truth about the medical insurance gap is that anyone can fall into this gray area of coverage, or rather, lack of coverage. As a medical insurance broker, it's important to recognize that a large portion of your client base may be affected. Medicaid is one of the major contributors to the medical insurance gap, particularly in states that didn't expand their programs. As of September 2016, 19 states had not expanded their Medicaid programs, leaving nearly 2.5 million people uninsured nationwide, according to the Kaiser Family Foundation. While California is not one of these states, it still has a growing population of adults who are under-insured, meaning that they have medical insurance, but their plans don't meet their medical needs. Throughout the years, more and more people have been falling into the medical insurance gap with varying levels of coverage. For example, many middle-aged adults have increasing medical needs due to their age, but they are leaving their health concerns untreated until they are eligible for Medicare at 65. Someone may also fall into the insurance gap if their coverage is limited by high deductibles or if the prescription medications they need are not covered. This leads to the obvious question, “What do all these people do when they are sick?” Even though many of these people don't have medical insurance, they still have access to medical care and prescription drugs. The difference is that they are responsible for these costs rather than the insurance company being responsible. Some of the most common out-of-pocket expenses that this population struggles to manage are basic medical procedures, such as a mammogram or colonoscopy, or medical equipment, such as wheelchairs. Another common burdensome cost is for their prescriptions, specifically high-cost medications for most chronic diseases. These can include Lisinopril (Prinivil) for high 14 | CALIFORNIA BROKER
BY JOSEPH SANGINITI
blood pressure, acetaminophen/hydrocodone pain medication (Vicodin), and depression and anxiety medications like sertraline (Zoloft). Medical adherence can become a major issue when under-insured people are responsible for these expenses. Patients may skip taking their prescribed medication to make it last longer, which could lead to a negative outcome. Many patients are not aware that medical discount programs and medical assistance programs can supplement their coverage to help close the coverage gap. Pharmaceutical manufacturers often offer these programs for the drugs they produce. However, eligibility varies by manufacturer. Another option is to use prescription assistance programs from third-party companies, some of which can save people an average of 43% on their prescriptions through a savings card or an app. There are many misconceptions about these programs. One is that the savings are limited or that it's difficult to qualify. Another misconception is that there are underlying scams or loopholes. How each company structures its prescription savings program varies, but these perceptions are generally false. The goal of these programs is to ensure that everyone has access to the medications they need without sacrificing their quality of life, financially and medically. Since we are in the midst of the 2017 open-enrollment season, one of the easiest ways to prevent someone from falling into the medical insurance gap is to make sure that they choose a plan that best suits their needs. This is when an insurance broker can provide the most value to their clients. When considering what type of coverage is best for your clients, here are three factors to take into account: 1. M ake sure that your client completely understands what their plan will and will not cover. Personalizing a medical insurance plan based on your client’s medical needs will help both of you determine what - CalBrokerMag.com -
the must haves are and what is extra. Asking the right questions, such as the type and the number of prescriptions they take, will ensure that they choose the right plan that covers this cost. This also helps prevent them from spending money for medical care they don't need. 2. R each a full understanding of what type of plan they are able to afford. Many people need coverage for specialty prescriptions and medical procedures, but their out-of-pocket costs are too expensive. Brokers should get in front of these changes and offer their clients the best options to help them manage costs. This could mean raising their premium to help them save money in the long run or helping them find ways to supplement their plan. If your client has a chronic medical condition, the best option could be to pay the higher premium to offset the outof-pocket costs. This could make the difference in your client spending a couple hundred dollars for their premium upfront or spending tens of thousands of dollars for the out-of-pocket costs they can accrue over the year. 3. Educate your clients on supplemental medical assistance and discount programs to further personalize their plans and help manage out-of-pocket costs. This is an ode to making sure that your clients are aware of all the options available to them. These programs offer a great way to supplement your client’s insurance without incurring additional costs and fees. These programs can also play a major role in helping all of your clients save money regardless of their coverage or lack of coverage. Joseph Sanginiti is CEO of FamilyWize, which offers a prescription assistance program through a free prescription savings card and app. Sanginiti has spent more than 25 years with several Fortune 500 organizations. As a senior executive in the pharmacy benefit management industry, he was responsible for the integration and management of pharmacy operations nationally. DECEMBER 2016