Open Enrollment Choices

By Michelle Fitzwater, Managed Care Contract Specialist

From September to December I get a lot of calls about insurance open enrollment, which is the time you can make changes to the insurance you choose from the plans offered by your employer.  For most people this is a mundane yearly task that they have to go through.  For people with a chronic condition it is a critical task that takes a lot of preparation and detective work.

In my last newsletter article I gave some hints about the questions to ask when you are faced with an open enrollment choice.  For one family those hints were not enough.  They have a self-funded insurance plan which means the employer pays the claims but uses an insurance company to manage the plan.  This also means that the employer has   control of the plan design and can make decisions regarding coverage that they think will work best.  This family was able to get a meeting with representatives of their employer as well as the insurance company they were considering.  Even though the family was well prepared and had done their homework they asked me to come in case there was a problem.

The first person we met with clearly explained the plan, out of pocket expenses and general coverage.  This is typical of most open enrollment contractors or HR staff.  He was sincere and helpful but did not have the answer to this family’s big questions: Where is our son's factor covered and can we continue to use the HoG pharmacy?

Our second meeting was with a head HR representative, a salesperson from the insurance company, and a salesperson from the specialty pharmacy selected by the employer.  There we got our answer.  The factor was not covered under medical but was covered by the drug benefit.  The employer elected to have all specialty medications run through the drug card company's specialty pharmacy.  This meant the family had to decide whether to select this plan  and use a new specialty pharmacy or to stay with the insurance plan they already had which does not require them to use a specialty pharmacy. 

Ultimately, they chose to keep the plan they had so they could continue to use the HoG pharmacy, which has been very helpful to them for many years.   Had it not been for all of their persistence and detective work they would not have known they had a choice to make and would have been forced to change to a specialty pharmacy chosen by the insurance company.

The decision you make should be based on your family's individual needs.  In order to have a choice you need to get all of the information first.  Ask questions about the coverage, limitations and networks you will have access to with each plan.  And don't stop f the first person you speak to doesn't know the answers.  Keep asking until you are satisfied that you have enough information to make the best decision for your family.