Tag: Blog

**Ideon is the company formerly known as Vericred. Vericred began operating as Ideon on May 18, 2022.**

Nearly 70% of Hospital Websites analyzed missed the mark.

A rule issued with much fanfare by the Department of Health and Human Services now requires that hospitals make their “chargemaster” public via the internet effective January 1^st, 2019. The chargemaster is a list detailing the official rate or list prices charged by a hospital for individual procedures, services, and goods.  There are no hospitals operating within the U.S. that are exempt under the new rule.

Much has been written about this new rule, with most experts correctly pointing out that very few people actually pay the chargemaster price because they have health insurance.  Instead, health insurance carriers and hospitals negotiate, seeking to reach agreement on lower costs for procedures for each carrier’s members.  In an ideal world, it would be the negotiated or contract reimbursement rates that would be made available online to patients.  If a carrier does not reach agreement with any given hospital, then charges incurred by that carrier’s members at that hospital are treated as out-of-network and/or billed at the chargemaster rate.

With this policy in place, prospective patients are being encouraged to look to hospital websites to understand the cost of services. However, if patients with health insurance will ultimately pay less, then it would be reasonable to also look to those same websites to determine whether the hospital accepts the patient’s health insurance plan.

You would think so… however, the Vericred team investigated further and revealed surprising results.

We took a look at the websites for 29 hospitals in the Columbus, Ohio area to analyze the accuracy of the insurance information they posted. Specifically, we zeroed in on the section of their websites that outlined “insurance(s) accepted,” with a focus on Individual Under 65 (ACA or “Obamacare”) plans, available from the four health insurance carriers offering coverage on Healthcare.gov.

We compared our findings to each health insurance carrier’s consumer-facing provider directory as the “source of truth.”

The results were stunning:

• Of the 29 hospitals analyzed, nine (31%) hospitals did not include information on which insurance they accept on their website.
• Of the remaining 20 hospitals, more than half provided incorrect information
• Only nine (or 45% of the hospital websites displaying such information) correctly conveyed whether or not they accepted one or more carrier’s ACA plans

Further, as a patient looking at these websites, there was a 9% chance that the hospital whose website they viewed actually accepted their plan, but showed otherwise — an avoidable false negative that could result in the patient going to different, less convenient, hospital.

Even more disconcerting, we found a 15% chance that the hospital will indicate that they take a plan when they do not — a false positive that has the potential to spiral into disastrous financial consequences to the patient. In this situation, the patient could select a hospital with the mistaken belief that their services will be covered by their insurance as in-network. Not only will that prove not to be the case, but the patient may well be billed at that chargemaster price which so few are.

The chargemaster ruling encourages us to look to hospital websites for the cost of services.  But the true cost of service depends on whether or not the hospitals accept the patient’s insurance and if so, the negotiated rates.  Hospital websites are not a reliable source for neither cost nor coverage.  Patients will still need to call their insurance companies to determine this information.

Moral of the story: Until hospitals update their website information with complete, accurate and timely information, patient beware — take a good look at the chargemaster; you may end up paying those rates!

**Ideon is the company formerly known as Vericred. Vericred began operating as Ideon on May 18, 2022.**

This is the third of three posts on this subject

In this blog series for Diabetes Awareness month, we are exploring how the medications used to treat diabetes are covered by ACA health insurance plans. In our last two posts, we showed that many plans exclude entire classes of diabetes medication and explored the prevalence of prior authorization requirements for insulins. In this post, we will walk through a real-life example of how much drug coverage costs for a common diabetes medication.

Lantus is a popular, long-acting insulin used to control blood sugar in people with diabetes. The data science team at Vericred reviewed several silver plans on the 2019 individual market in the state of New York to see what the yearly cost of Lantus would be assuming one carton of Lantus injection pens per month; GoodRx estimates the cost for one carton to be $281.

An individual in New York covered by one of these silver plans will pay anywhere from $480 to $3,372 out-of-pocket for a year of Lantus. That’s up to seven times as much for the same medication. Real life is more complicated than this—most diabetes patients will see multiple doctors and fill a variety of prescriptions—but this simplified example illustrates the importance of carefully researching your health insurance options.

The out of pocket cost for Lantus depends on more than the premiums, deductibles, out of pocket maximums, and cost sharing for prescriptions. The widespread in the cost of Lantus is due to differences that may be harder to notice. Plan 1 does not apply the deductible to drug costs, meaning that from the first dollar the individual pays only the copay for Lantus. Plan 2 has a separate (and much lower) deductible specifically for drugs. Plan 3 requires the full deductible to be met before the copay applies. There are also differences in the plans’ formularies. Plans 1 and 3 cover Lantus as a preferred brand drug. Plan 2 covers Lantus as a non-preferred brand drug, meaning the cost sharing is higher than it would be for a preferred brand—in this case, a percentage of the drug’s cost rather than a flat copayment). The formulary for Plan 4 does not cover Lantus at all, meaning the plan will not pay for any portion of the drug’s cost. It is worth noting, however, that the total cost of healthcare (including premiums) for Plan 4 is actually the second lowest of the four example plans. Somewhat counterintuitively, a plan that does not cover the drugs you need might be less expensive, depending on the premium and other plan characteristics.

Formulary coverage and to which benefits the deductible does and does not apply are two easily overlooked aspects of health insurance design that shoppers need to be aware of when evaluating plans, but they need to be considered in combination premiums and other plan features to determine which will best meet your needs.

**Ideon is the company formerly known as Vericred. Vericred began operating as Ideon on May 18, 2022.**

 

This is the second of three posts on this subject

In this blog series for Diabetes Awareness month, we are exploring how the medications used to treat diabetes are covered by ACA health insurance plans. In our last post, we showed that many plans exclude entire classes of diabetes medication. In this post, we will explore the prevalence of prior authorization requirements with a focus on insulin.

Prior authorization is a tool that formularies can use to control access to certain medications. Although drugs with a prior authorization requirement are covered, providers are often hesitant to go through the approval process. From a patient perspective, this can be similar to the drug not being covered. The data science team at Vericred investigated the coverage for diabetes medications under ACA small group and individual plans to see how often they are subjected to prior authorization requirements.

The results show that prior authorization requirements are quite common. The majority of plans require it for at least one of the 53 diabetes medications studied. All nine medications in the insulin class require prior authorization from at least some plans. Individual plans are more likely to require it than are small group plans. The most striking example of this is Apidra – 37% of the individual plans that cover this drug require prior authorization compared to an 8% of small group plans.

Consumers with diabetes and employers shopping for insurance plans need to look carefully at the formulary information for the plans they are considering. Even if a drug is covered, some plans place additional requirements like prior authorization that can limit access to certain medications.

**Ideon is the company formerly known as Vericred. Vericred began operating as Ideon on May 18, 2022.**

 

This is the first of three posts on this subject

Diabetes is one of the most common diseases in the United States as well as a leading cause of death. It affects nearly 10% of Americans, and its prevalence has been steadily increasing over the past several decades. Treatment for diabetes is complicated, often requiring several medications. In this Diabetes Awareness month series, we will explore characteristics of how the medications used to treat it are covered by ACA health insurance plans.

Vericred’s data science team investigated how 53 diabetes medications broken into 17 different classes based on their mechanisms of action are covered by small group and individual health plans. The results show that insulin along with biguanides (e.g., metformin) and sulfonylureas (e.g., glipizide), two of the oldest drug classes used to treat diabetes, have at least one member drug covered by every small group and individual plan. The remaining 14 of 17 drug classes are excluded entirely by at least some plans.* About two thirds of small group and individual plans have at least one class for which they do not cover any drugs. Individual plans are more likely than small group plans to exclude medication classes; 45% of individual plans exclude three or more classes compared to 9% of small group plans.

Consumers with diabetes, and employers shopping for insurance plans, should consider their plan options carefully, as coverage options for diabetes drugs are can vary widely across plans. This is particularly important for those with diabetes already on medication—if a new plan does not cover any drug in the same class as their current medication, their costs will rise greatly or their treatment regimen will need to change.

**Ideon is the company formerly known as Vericred. Vericred began operating as Ideon on May 18, 2022.**

In our last series of blog posts, we showed that health insurance carriers are becoming increasingly more likely to offer generous benefits for urgent care compared to the emergency room. While urgent care was conceived as a more convenient and lower cost alternative to the emergency room, it is also being used as an alternative to primary care—particularly, as a recent survey shows, by millennials. In this Veristat post, we will investigate cost sharing for urgent care compared to primary care.

The data science team at Vericred analyzed the benefit designs for health insurance plans on the individual and small group ACA markets to study the difference in how the costs for primary care and urgent care are split between individuals and their health insurance companies. The results show that for both primary care and urgent care, most silver and gold plans share the cost before the deductible, while most bronze plans do not. For all three metal levels, primary care is somewhat more likely to be covered before the deductible than is urgent care. This difference is larger for bronze plans than for silver and gold and larger for the individual market than the small group market. Across all three metal levels, the most common type of cost sharing for both benefits is a copay regardless of whether the deductible has been met; on the individual market, the median copays are $30 for primary care and $75 for urgent care.

While cost sharing is somewhat more generous for primary care than urgent care, there is a much smaller difference between these benefits than we previously found for urgent care vs. the emergency room. The way health insurance carriers structure their benefits influences the way their beneficiaries use the healthcare system. It is worth asking whether the difference between cost sharing for primary care and urgent care is slight enough to reinforce the growing shift towards urgent care as an alternative to having a regular doctor. While urgent care has some advantages, including extended hours for patients who may be unable to take time off work, using it as an alternative to a regular doctor leads to a more fragmented pattern of care. Health insurance carriers should consider how their benefit structures incentivize beneficiaries’ behaviors and how these behaviors will affect health.

**Ideon is the company formerly known as Vericred. Vericred began operating as Ideon on May 18, 2022.**

This is the third of three posts on this subject

In our last post, we showed that the cost sharing for urgent care tends to be more generous than the cost sharing for emergency room visits. In this post, we investigate how that difference in cost sharing between emergency rooms and urgent care has changed over time.

The data science team at Vericred analyzed the benefit designs for health insurance plans on the individual and small group ACA markets from 2015 to 2018 to see the how the difference in the way the costs for emergency room and urgent care are split between individuals and their health insurance companies has changed over time. The results show that over the past few years, insurance companies have become increasingly more likely to share cost before the deductible for urgent care than for the emergency room. This difference in the cost sharing structure between emergency rooms and urgent care is increasing over time for both audiences and all metal levels.* Urgent care clinics have become increasingly common in the past few years, and insurance companies may be shifting increasing portions of the cost of emergency room visits onto consumers in order to restrain costs by encouraging a shift in usage away from emergency rooms and toward the lower cost urgent care clinics.

Consumers and policy makers should keep an eye out as the 2019 open enrollment period approaches to see how insurance companies continue to modify their benefits in this shifting dynamic between provider types.

* Platinum and catastrophic plans excluded. Catastrophic plans typically have a deductible equal to the out of pocket maximum, which removes cost-sharing variation. Platinum plans often have a $0 deductible, meaning there is no distinction between before and after the deductible.

**Ideon is the company formerly known as Vericred. Vericred began operating as Ideon on May 18, 2022.**

 

This is the second of three posts on this subject

As we discussed in our previous post, emergency room visits are not only one of the most common interactions people have with our healthcare system, but they can be quite expensive for both individuals and their insurance companies. In recent years, urgent care clinics have emerged as a cheaper alternative to the emergency room for less severe conditions like the flu and injuries that occur outside traditional providers’ business hours and for folks without a regular doctor. In our analysis, we showed that insurance companies are more likely to share costs before the deductible for urgent care than for the emergency room. In this post, we take a deeper look at the structure of that cost sharing.

The data science team at Vericred analyzed the benefit designs for silver plans on the individual market to investigate how cost sharing between individuals and their health insurance companies is structured for emergency rooms versus urgent care. The results show that the most common type of cost sharing for emergency room visits is a coinsurance that applies only after the deductible has been met (median: 25%). This means that an individual would pay the full cost until her deductible is met, then a set percentage of the emergency room charges above that. In contrast, the most common type of cost sharing for urgent care is a copay that applies regardless of the deductible (median: $75). This means that an individual would pay a flat dollar amount regardless of the charges for the urgent care visit and whether or not she has met her deductible.

In advance of finding yourself footing a costly bill, it’s worth checking your insurance coverage to see the difference in the way emergency room and urgent care visits are covered. You may end up significantly reducing your healthcare expenses should you experience an urgent medical condition when the option to see your doctor is not available.

This is the second of three posts; in the next post, we will investigate how the difference in emergency room cost sharing has changed over time.

**Ideon is the company formerly known as Vericred. Vericred began operating as Ideon on May 18, 2022.**

 

This is the first of three posts on this subject

Emergency room visits are one of the most common interactions people have with our healthcare system, and they can be quite expensive for both individuals and their insurance companies. In recent years, urgent care clinics have emerged as a cheaper alternative to the emergency room for less severe conditions like flu and minor injuries that occur outside traditional providers’ business hours and for folks without a regular doctor.

The data science team at Vericred analyzed the benefit designs for health insurance plans on the individual and small group ACA markets to see the difference in the way the costs for emergency room and urgent care are split between individuals and their health insurance companies. The results show that for both markets and all metal levels,* insurance companies are more likely to share the cost before the deductible for urgent care than for the emergency room. This means that an individual who has not yet met her deductible might have to shoulder the full cost of an emergency room visit, while the cost for the same visit at urgent care would be shared with her health insurance company.

It’s worth checking your insurance coverage to see the difference in the way emergency room and urgent care visits are covered—it could end up saving you money if you experience an urgent medical condition when the option to see your doctor is not available.

* Platinum and catastrophic plans excluded. Catastrophic plans typically have a deductible equal to the out of pocket maximum, which removes cost-sharing variation. Platinum plans often have a $0 deductible, meaning there is no distinction between before and after the deductible.

This is the first of three posts; in the next post, we will look more deeply at the difference in the way that cost sharing for emergency room and urgent care visits are structured.

**Ideon is the company formerly known as Vericred. Vericred began operating as Ideon on May 18, 2022.**

 

This is the third of three posts on this subject

The Affordable Care Act regulates both the individual and small group health insurance markets, yet these two markets are seldom looked at side by side. While many of the regulations governing plan design and premiums are the same, the markets serve very different populations and different health insurance carriers participate.

In our last post, we investigated how competition in the individual market is related to the premium difference between the individual and small group markets. In this post, we will examine how the premium difference between the individual and small group markets has changed over time.

The data science team at Vericred analyzed the difference in premiums between the lowest cost plans on the individual and small group markets for each metal level to see how the premium difference between these markets has changed over the past few years.* The results show that the individual market was slightly more expensive than the small group market in 2016 and that the individual market became increasingly more expensive than small group market for all metal levels in 2017 and again in 2018. The individual market is showing signs of growth for 2019 after a large number of exits in 2018. Consumers and policy makers should take note as 2019 rate filings are released to see if this trend of divergence in premiums between the individual and small group markets continues or begins to stabilize.

* Trend over time is similar, but less extreme, if the median cost plans for each metal level are used instead of the lowest cost plans

**Ideon is the company formerly known as Vericred. Vericred began operating as Ideon on May 18, 2022.**

 

This is the second of three posts on this subject

The Affordable Care Act regulates both the individual and small group health insurance markets, yet these two markets are seldom looked at side by side. While many of the regulations governing plan design and premiums are the same, the markets serve very different populations and different health insurance carriers participate.

In our last post, we examined the difference in premiums for the lowest cost silver plans on the individual and small group markets. In this post, we will investigate how competition in the individual market is related to this premium difference.

The data science team at Vericred compared the difference in premiums for the lowest cost plans on the individual and small group markets to the percentage of “one-carrier counties”— counties with only one health insurance carrier offering on-market individual plans.* The results show a moderately strong relationship between lack of competition and increased premiums on the individual market. Of the five states where individual premiums are less expensive than small group, three have no one-carrier counties. The other two, Ohio and Indiana, have approximately half one-carrier counties but have heavy involvement of Medicaid Managed Care Organizations in the individual market, which tend to have somewhat lower premiums than other carrier types. All of the states where individual premiums are the most expensive compared to the small group have either mostly or exclusively one-carrier counties.

* Results are similar if the median cost silver plan is used instead of the lowest cost silver plan

This is the second of three posts; in the next post, we will investigate how the premium difference between the small group and individual markets has changed over time.