P L A N

MSAA recognizes that selecting a healthcare-insurance plan can be confusing and, at times, overwhelming. To help lessen confusion and better prepare you for this important decision, MSAA has created a simple acronym that identifies key areas to consider when planning for your health-insurance coverage. Prior to making your insurance selection, we encourage you to PLAN ahead (Prepare, Look, Analyze, and Name).

P Prepare a budget:

When considering purchasing an insurance plan you first need to carefully evaluate the full anticipated cost of medical expenses. This will include items such as the following:

• Concrete costs such as your monthly premium and your annual deductible, which you can calculate up front.
• Other more subjective costs, including projected co-pay and co-insurance amounts that you might spend during a plan year on:
  • Medications
  • Primary care and specialty appointments
  • Hospitalizations
  • Needed equipment or medical procedures

Another important figure is the plan’s “maximum out-of-pocket” that should be the limit on your expenses you will pay for policy coverage. Generally this is an annual maximum. It is important to note the “maximum out-of-pocket” does not include the amount you pay in plan premiums and may also exclude services provided from out-of-network providers or non-covered health services.

In 2014, the maximum out-of-pocket cost for a Marketplace plan can be no more than $6,350 for an individual plan and $12,700 for a family plan. However, in 2014, some insurance plans may have separate insurance and pharmacy out-of-pocket limits that could increase this overall cost.

The Marketplace provides four different levels of coverage, categorized in a Medal system of levels (Bronze, Silver, Gold, and Platinum):

* Some Silver level plans may also allow people to qualify for co-pay and deductible assistance

When preparing a budget, be sure to consider the following questions:

1. Which plans can I afford?*
2. Can I afford my deductible?
3. What are my expected out-of-pocket costs for items (such as durable medical equipment, or DME) and procedures (such as magnetic resonance imaging scans or MRI) that I may need?

1. Which plans can I afford?*
   • When you enter the Health Insurance Marketplace, you will be asked about your income. The amount that you enter will determine whether you may be eligible for Medicaid in your state, if eligible for CHIP (Children’s Health Insurance Program), if applying for insurance for your children, or whether your family will qualify for insurance-premium assistance.
   • If you do qualify for Medicaid or CHIP, your registry information will be directly sent to the correct government office.
   • If you qualify for premium assistance, you will be immediately notified of the amount of credit you will receive toward your premium.
   • It is very important to note that if your income changes throughout the year (if you lose a job, get a raise, etc.), you must notify the state so that they can adjust your premium as needed, or determine whether you may then qualify for Medicaid. If you fail to notify the correct party, you may get less assistance than you qualify for, or you may be forced to pay back some of the awarded premium credits.

*Please note: Many individuals will be eligible to receive a monthly premium credit that will reduce the out-of-pocket expenses for the cost of the insurance plan. If eligible for a credit, you would reduce the monthly premium amount listed to only your projected cost. Sometimes a higher premium may be merited if it reduces the deductible and out-of-pocket expenses required to receive needed equipment items. Please note that if you are eligible for cost savings you will only receive financial help if you select a Silver-level plan.

1. Can I afford my deductible?
   • Many plans may require you to pay a $500 to $2,500 deductible before the coverage of costs becomes available so make sure your budget reflects these costs.
2. What are my expected out-of-pocket costs for items (such as durable medical equipment, or DME) and procedures (such as magnetic resonance imaging scans or MRI) that I may need?
   • Example of budgeting projected costs:
     

     Monthly Premium	Deductible	DME	Medication	MRI (radiology)
     Example 1: $300(x 12 months)	$500 per year	20% co-insurance after deductible	Tier 3: $50 co-pay(x 12 months)	$125 co-pay after deductible(x two per year)
     Total: $3,600	$500	$85	$600	$250
     Example 2: $250(x 12 months)	$1000 per year	20% co-insurance after deductible	Tier 3: $50 co-pay (x 12 months)	20% co-insurance after deductible(x two per year)
     Total: $3,000	$1,000	$85	$600	$700

     View Larger Chart

     

     In example 1, the monthly premium is higher, but the annual deductible and MRI costs are lower. The total out-of-pocket expense is: $5,035.

     In example 2, the monthly premium is lower, but the annual deductible and MRI costs are higher. The total out-of-pocket expense is: $5,385.

     In this scenario, assuming the person gets one durable medical equipment (DME) item, two MRI scans, and has the same medication costs, selecting example 1 will save $350 that year.

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L Look carefully to determine what each plan covers:

All plans are not created equal and will have differences in covered medications, as well as in-network and out-of-network hospitals, doctors, and allied health professionals. Plans may also have differences in costs and coverage for different medical procedures and medical equipment. You may have to pay higher out-of-pocket fees or the full medical cost of a service or medication if it is not covered under your policy or you chose an out-of-network provider or facility for health services.

When looking at potential coverage options, consider the following questions:

1. Can I keep the same doctors and are there any restrictions for selecting doctors in my new potential plan?
   • Many insurance plans have networks of doctors, pharmacies, hospitals and outpatient clinics which are considered in-network or out-of-network.
   • In-network service providers and facilities will generally receive the highest payments or reimbursement rates from insurance companies. Seeing an in-network provider or using an in-network facility may significantly reduce your personal out-of-pocket medical costs.
   • Your insurance may charge a higher co-insurance or co-pay to see out-of-network providers or many not provide any coverage for out-of-network providers or facilities.
   • Be careful if you are using a hospital. Just because you are seen at an in-network hospital does not necessarily mean that every provider you see within that hospital is in-network. Before scheduling a procedure or receiving care, check to make sure the providers you will see are all in-network.
2. Are my needed medications covered, and if so, how much will they cost?
   • Every insurance plan will provide a drug formulary or a list of prescription medications which are covered under your policy. You should check your drug formulary every year at open enrollment, as plans can change which drugs are covered at any time.
   • Try to find a policy which covers all of your needed medications, or at a minimum, your most costly medications.
   • If your insurance policy notifies you mid-plan year that a previously covered, medication is no longer being covered you may try to appeal the medication denial with the help of your physician.
3. Are there any restrictions to access for my current medications including “steps,” tiering, or quantity limits. See Healthcare Insurance Glossary.
   

   Tier 1	Tier 2
   The generic version of a brand-name medication; active ingredients are the same.	Brand-name medications that are on a list of preferred drugs.
   Tier 3	Tier 4
   Brand-name medications with Tier 1 or 2 equivalents or preferred specialty brand-name drugs.	Medications that require special dosing or administration; typically prescribed by a specialist and more expensive.

   Tier 1

   The generic version of a brand-name medication; active ingredients are the same.

   Tier 2

   Brand-name medications that are on a list of preferred drugs.

   Tier 3

   Brand-name medications with Tier 1 or 2 equivalents or preferred specialty brand-name drugs.

   Tier 4

   Medications that require special dosing or administration; typically prescribed by a specialist and more expensive.

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A Analyze your options:

Once you have narrowed your choices to a few options, you will need to prioritize which plans fall within your budget and look at the coverage options side by side. This is where you will make a determination about what matters the most to you: out-of-pocket costs, having your doctor in network, having more medication choices, etc.

Questions to Consider:

1. Which plan offers the most flexibility (access to medications, doctors, procedures, etc.)?
2. If I need to change my MS medication, what other drug options will be available to me?
3. Have I weighed the “pros and cons” for my insurance plan, and are there other “what if” questions to consider?

1. Which plan offers the most flexibility (access to medications, doctors, procedures, etc.)?
   • When analyzing the plans which fit your budget, also consider your priorities. Is it most important for you to have a plan which covers a particular hospital, doctor, or medication?
   • You will need to evaluate whether you are willing to pay more for access to a wider network of doctors or hospitals or whether you may be willing to change providers if it will reduce your overall expense.
   • Just because a plan costs more does not mean it provides better access to hospitals, doctors, or medications so remember to evaluate covered services, medications, and providers carefully depending upon your priorities.
2. If I need to change my MS medication, what other drug options will be available to me?
   • Most people will check to make sure their current MS medication is covered before purchasing a plan. However, it is also wise to check all MS medications covered under the plan to ensure your alternate choices are viable options.
   • If your current or suggested medication is covered but the alternative medications on the policy’s drug formulary are not a good fit, you will need to have a plan in place for what will happen if you need to change medications during that plan year.
3. Have I weighed the “pros and cons” for my insurance plan; are there other “what if” questions to consider? Create a “pros and cons” list or some “what if” questions based on your healthcare needs:
   • When comparing the plans that may be best for you, be sure to evaluate the real costs of the anticipated co-pays for your medications, estimated DME, and MRI (or any other common medical procedures you need), in addition to the monthly premiums and deductible amount.
   • Create a pros and cons list of your top two or three plans and place them side-by-side. One plan may stand out as having an edge over the others, or one may have a priority advantage (such as covering your MS doctor or MS medications) that other policies cannot match.

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N Name your insurance plan by making a selection on the Marketplace:

When you have looked over your budget, listed the pros and cons of each plan, and carefully considered what you feel may be the best option, you are then ready to select a policy.

You can select a policy by visiting www.healthcare.gov or you can receive assistance by phone or request in-person assistance by calling an insurance Navigator at (800) 318-2596.