Where is Flo when I need her cheery optimism???

October 20, 2011 3:03 PM

I'm in the open enrollment period (also newly married) and am considering switching health insurance -- for the first time ever. I understand the fill-out-the-forms part, but I can't wrap my head around what that means logistically. What's the process? What should I look out for?

I work for a large state university, which is also my alma mater and father's employer. I have had the same health insurance since age 10. I kind of hate the HMO and have often been tempted to switch, but I'm always stymied by the prospect of all the stuff I would have to do w/r/t switching doctors, etc. Also, trying to navigate insurance is my 100% least favorite thing in the world. I DO NOT UNDERSTAND.

When my husband got a new job/insurance, it took him a while to get in with a new PCP... and then it took him a while to get in with a specialist for something the PCP found... and I don't think I can wait that long for certain things.

So pretend I am Unfrozen Cavewoman Consumer here. Your insurance frightens and confuses me. Let's say I fill out the forms and this goes into effect in January. What happens?

--Medications: I have fairly simple prescriptions for an antidepressant and an ADHD drug. I see a psychiatrist for a med check every 6 months or so, but am currently between therapists (and fine with that for now). Do I need to stock up somehow? What happens to my six-month prescription at the drug store when I suddenly switch HMOs -- do I, or the doctor I'm leaving, call someone on January 2 and say, "she's cool; give her a refill" so my continuity doesn't get messed up?

--Picking a doctor: do I just solicit recs for PCPs from friends or whatever and then make an appointment for a physical or some other sort of baseline checkup? And with the waits I'm used to, how soon can I get in with a psychiatrist (see above) for an intake?

--Spousal benefits: he works for a private company which provides crappy Blue Cross/Blue Shield, but he sees people in the HMO I would likely join. Should I add him on my way-better state plan? If so, should he stop paying for his own coverage or keep it in case of emergencies? (I believe that we are allowed double coverage as long as he's not a state employee.)

--And then there's the fact that my job will technically end in June. Joy.

Help?

posted by Madamina to work & money (6 answers total)

In my experience, double coverage is not worth it. Insurance #1 says they will pay 90%. Insurance #2 says they will pay 75%, but insurance #1 already paid that so they won't pay anything now.
posted by yb2006shasta at 3:25 PM on October 20, 2011 [1 favorite]

Do I need to stock up somehow?

Your current prescription plan might limit you to a prescription that fills your current dosages, up to your coverage date range. If your prescription plan is separate from your health plan, you might give those folks a call and ask. Worst case scenario is that you're stuck with whatever they will give you.

Does your employer offer a grid-like layout of plans and coverage options? It may come down to researching what they offer.

In my case, when I was forced to switch at my university job, I was given three options. Two of the options were with Kaiser Permanente and Group Health, which would have required switching doctors in mid-treatment(!). So I opted for the plan which would allow me to keep my doctors, but would still keep me in-network and allow access to a local emergency room.

Figuring this our required some research on web sites and phone calls to plan support staff to answer questions.

It's not fun, juggling this stuff when you're in the middle of needing care. But that's the health system our politicians gave us. Good luck.
posted by Blazecock Pileon at 3:29 PM on October 20, 2011

Ask your current doctors if they take the prospective policy. If they do, it should be painless. If they don't, ask them what they suggest you do. Maybe they will choose to accept that insurance, or give you a referral to a new doctor.

If you have to change doctors, it really depends on the new doctor. Sometimes they are fine with accepting the old doctor's diagnosis and treatment plan, and sometimes they will do a "oh, no, no, no, this is all wrong, we have to start over" routine. Either has its pros and cons.
posted by gjc at 4:14 PM on October 20, 2011

Find out whether the medicines you're taking are on the formularies for the plans you have to choose from. Also, whether they'll require you to switch to generics, if you're not already on them & brand vs. generic matters to you. Also find out whether they force or incentivize you to use mail-order pharmacy, if that would influence your decision.

I'd suggest getting as big a refill as you can before the switchover date, and soon after that date, check with the pharmacy to make sure they deal with your new insurance & don't see any problem filling them under your new plan. It shouldn't matter that you've changed doctors until the point when you run out of authorized refills and need to get a new prescription written, at which point of course you'll get it from your new doc, if in fact you do have to change docs. Most of them take several types of insurance unless they work for a group-model HMO, and those aren't so common anymore.

You might ask your current docs for recommendations about who to choose among the providers who participate in your new plan, again assuming they themselves are not participating providers.

But with your job ending in a few months? Breaking your continuity of care doesn't seem worthwhile, imo.
posted by lakeroon at 8:16 PM on October 20, 2011

your job ends in June? let hubby keep his insurance, and find out now what you'll have to do to get added to it after your job ends. crappy bc/bs is better than nothing.

Oddly enough, it costs us MORE to have single coverage than double - I chose to drop my work coverage and go with insurance through my husband's employer, and since I turned down available insurance from my own employer, his makes us pay an additional $xx per week. So, find out if either/both of you would pay that sort of penalty, and do what's cheapest for you between now and June.

are you 100% positive you'd have to get a new doc? If you have a PCP right now that you like, call their office, tell them your options for insurance, and ask if he/she participates in those plans. We've switched insurance around a few times but haven't had to switch docs. last time I just went to the new plan's website for consumers and searched the directory for our docs to make sure they were listed.

again, YMMV, but we've had insurance switches when I'm in the midst of year-long prescriptions and I've never had a problem refilling - the pharmacist takes the new drug card, runs it, and updates the info in my file. the scrip itself is still good. talk to your pharmacist to make sure, though. if you can get more than a 30-day refill these days, count yourself lucky and stock up to be safe.

re: finding a new PCP and wait times - it is perfectly OK to tell the office staff that you have an existing condition, are switching docs for insurance reasons, and need to get into the system quickly. tell them when your scrips expire, for example, and that you need a PCP and referral to a specialist before then. sometimes you have to be the squeaky wheel.
posted by hms71 at 9:08 PM on October 20, 2011

To clarify: I want to switch partially BECAUSE I want new doctors, specifically primary care. The people I see right now are all at the various clinics operated directly by my current health system. (Except for my PCP, but his office is so inconvenient that... yeah, location is another concern.)
posted by Madamina at 5:51 AM on October 21, 2011