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OCHC Working to Fix Health Plan Problems

Ohio Consumers for Health Coverage has been building a feedback loop to learn about the experience of early users of the new Marketplace plans.  Our goal is to advocate both with the health insurance companies that have issued the plans, and to advocate with the Ohio Department of Insurance. We invited organizations that help people and might be hearing about the problems to be part of the feedback loop.

Themes that emerged from our first call held March 12th were that some health plans do not have clear drug formularies.  This means that health plan shoppers cannot tell before they purchase a plan what drugs are covered at what cost.  In many health plans, drugs are put in “tiers” roughly as follows:  Tier 1 (generic); Tier 2 (preferred brand name drug); Tier 3 (non-preferred brand name drug) and Tier 4 (specialty drug). The co-pays or co-insurance required from the plan participant gets higher as the numbers go up.  But in some plans the buyer can’t tell from the web site, what the co-pay will be for the various tiers.  And in some cases it appears that anything that is not generic or a preferred brand requires prior authorization before it can be filled at a drug store. Such plans can discourage people with chronic illnesses from signing up, and can result in insurance companies managing risk by excluding people rather than managing risk by having good chronic disease plans.

Another theme that emerged was disappointment in the cost-sharing associated with health plans.  Many bronze level plans provide very little service before the insured person meets the deductible.  Some purchasers did not understand that and now feel they are spending a lot of money per month and seeing no benefit for it.  People helping those purchasers are concerned that these plan participants could end up in bankruptcy—something we don’t want to see in the post-January 1st ACA world where coverage should be available and affordable.

These are the two themes that so far we are most concerned about and centering our advocacy around.  We invite our readers to let us know what they are seeing.  One way to do that is to go to this survey: If you would like to be a part of the feedback loop calls, please contact Kathleen Gmeiner at [email protected]