Health sign-ups will be much clearer

Peter Lee, left, executive director of Covered California, poses with enrollees in the state’s health insurance exchange.
Peter Lee, left, executive director of Covered California, poses with enrollees in the state’s health insurance exchange. The New York Times

Californians have started to sign up for health plans through Covered California, the state’s health insurance exchange. During the first enrollment last year, the exchange registered about 1 million people, but many consumers struggled to find answers to simple questions about the plans.

It will be much easier for Californians to get the information they need this time around. Gov. Jerry Brown signed two bills that require insurance companies to be more transparent about the health plans they sell through the exchange.

For instance, starting in January, Covered California’s website will directly link to the drug benefit details of available health plans. By mid-2017 insurers must post online the list of drugs covered by their plans, known as formularies, using a standardized format. The California Department of Managed Health Care is now required to report whether plans sold through Covered California include enough doctors and specialists accepting patients and whether enrollees can get appointments in a timely manner.

Brown deserves our applause. With two out of every five Californians suffering from chronic illnesses – such as heart disease, cancer, diabetes, or multiple sclerosis – it is extremely important for consumers to have the information they need to better understand the plans sold through the insurance exchange.

If patients pick the wrong plan, they might have to pay a substantial portion of their drug costs out of their own pocket. The difference in out-of-pocket costs could vary widely, depending on the plan.

Typically, a formulary classifies medicines according to several tiers. Tier one might require only a small co-pay, like $20 for a blood thinner. Drugs in the higher tiers come with higher out-of-pocket costs. Tier four – or a specialty tier – usually involves co-insurance, which is a requirement that patients pay a set percentage of a drug’s cost, no matter the price.

Previously, the only way enrollees could attain important plan information was to directly contact each insurance company and go over exhaustive details with a company representative. This time-consuming and inefficient process only led to frustration and confusion, which led to real suffering.

Consider the story of Charis Hill of Sacramento. She suffers from a rare form of arthritis called ankylosing spondylitis, which causes vertebrae in her spine to fuse together, restricting her movement and causing considerable pain. This condition is manageable with a weekly shot of a medication called Enbrel.

Last year, Hill tried to get insurance through California’s exchange. But even with the assistance of a navigator – someone who helps people find the right coverage for them – she still couldn’t figure out exactly how much her Enbrel prescription would cost her under various plans. She became so confused that she missed the deadline to sign up for coverage. As a result, she was automatically placed in a default standard plan, and her medication costs jumped from $5 a month to $2,000.

Patients were also frustrated by not being able to get a doctor’s appointment under their new health insurance plan; Covered California enrollees filed more than 300 complaints between January and August. The new legislation will require insurance companies to disclose which doctors participate in which plans.

“Patients should be focusing on their health, not on sorting through packets of insurance paperwork,” said Sen. Norma Torres, chief sponsor of the prescription drug cost transparency bill.

Californians need coverage that actually minimizes their health care costs. And to find the right coverage, they need easy access to key details about drug formularies and covered providers.

Thanks to these reforms, patients signing up for insurance will be provided essential information about the health insurance plans sold through the state exchange. This is a major victory for patients.

Marc Boutin is executive vice president and chief operating officer of the National Health Council.