- Claims utilization or the people using services are coming in at a 3 times higher rate than have been expected so people are using services at a much higher clip then they have been in the past.
- The cost for RX prescription drugs under the plans have gone up double digits and that’s impacting the rates. Specialty drugs have a huge impact. If one person is taking a very expensive specialty drug, those claims are spread out over everybody.
- Probably the most important reason is there are people who are actually gaming the system in a way it was not originally intended. We have people enrolling during the open enrollment period, using services, then dropping insurance. That’s not the way the system was intended to be used. We also have a lot of people who are not enrolled in the system. The result is people going in and out and using services, and people who are not enrolling are greatly affecting the cost of insurance for the people who are covered.
I think going forward, people are going to be scrutinizing their plan and making sure that they get the value of their health insurance and are not overpaying.
Other than the major rate increases, what else is new for 2017? For those people covered under Anthem Blue Cross on individual plans which is currently a PPO plan, Anthem Blue Cross is switching from PPO to an EPO style plan in 2017. Their individual plans were the EPO style plan in 2014 and 2015; this year they went to the PPO and now they’re back to the EPO. Of course, people prefer the PPO plans because it has an out-of-network benefit. The reality is the PPO plans that have out-of-network benefits are not used frequently so switching from the PPO to the EPO next year is really not going to affect a lot of people. The exception that’s a little aggravating is not having non-emergency services covered out-of-network on your plan. Blue Cross says over 90% of their claims are with in-network providers so they don’t have a lot of out-of-network claims. It makes their insurance more affordable, even with these large rate increases, to have an EPO instead of the PPO.
Another thing that we’re going to see next year, which is mandated by the government, is that all individual EPO and PPO plan that are new or ACA compliant plans will now be assigning a primary care physician to each member that will show on your ID card. For example, it will say Dr. Fred Smith is my primary care doctor. Don’t be alarmed by this; it is not like an HMO and it’s not a gatekeeper with someone telling you what services you can and can’t use. They are just putting in either a doctor you are using or a doctor who is in close proximity to your residence. The feeling of the government is that by assigning a primary care doctor, it will promote preventive care. People who don’t use health insurance at all are going to look at their card and say “Oh, I’m going to go to Dr. Fred Smith because he’s on my card and I need to get a checkup”. If you’re on an EPO plan or PPO plan and you want to go to Dr. Jerry in-network, it doesn’t affect anything. In fact, you can even change that primary care doctor after they assign it to you. Don’t worry by what you see on your ID cards that will be mailed to you in the 1st quarter of the coming year.