fbpx

Why Your Prescriptions Cost So Much; And What To Do About It

The high cost of prescription medications is driving American families into bankruptcy. And it doesn’t look like there is any relief in sight. The average person in the U.S. is prescribed 12 prescription medications each year. Those 65 and older fill, on average,  27-29 prescriptions annually. 

In 2019, retail prescription drug spending climbed by 5.7% to $369.7 billion according to the Centers for Medicare and Medicaid Services (CMS). In January 2021,  GoodRx reported that 832 drugs had an average price increase of 4.5%. 

Americans had an average per capita healthcare spend of $11,172  in 2018.  As a result, they collectively borrowed $88 billion, skipped necessary medical treatment, and cut back on their household expenses just to pay for basic medical care. 

Unfortunately, strategies that work for other major purchases, such as shopping around, have not proven to be effective in finding affordable medical care; 69% of adults surveyed said that when they tried to shop around, the process was rated as somewhat or very difficult. 

Drug pricing needs to be more transparent so Americans can comparison shop just like they do for other consumer goods and services. 

After exploring why an unregulated, patent-protected pharmaceutical market with a supply chain that governs its own supply and demand keeps prescription drug prices exorbitantly high, we’ll look at how you can fight back against high prices and get your prescription medications as affordably as possible. 

The Reasons Prescription Drugs Are Outrageously Expensive In The U.S.

Prescription pricing is a complicated issue, as there is a conflict between personal and societal goals. Society may want to keep drug prices under control, but families are prepared to put themselves at great financial risk to pay for a potentially life-saving prescription for a loved one. 

When people’s lives are at stake, it’s difficult to conduct a thorough risk versus benefits analysis. Unlike goods and services that are not potentially life-saving, traditional economic forces do not limit prescription drug prices. People are not willing to forego medications simply because the cost is too high, nor should they be forced to do so. 

Drug prices in the United States are 2.56 times higher than in any other industrialized country overall, and 3.44 times higher for brand name drugs, due to the following factors: 

  • Pharmaceutical companies get up to 20 years of patent and exclusivity protection to market their products without competition. 
  • Unlike other industrialized countries, the U.S. government does not impose price controls. The FDA controls how drugs are produced but have no power to regulate pricing. 
  • Doctors are frequently uninformed about prescription prices and consumer costs, which means they do not always prescribe the most cost-effective medication to treat a given condition. Unfortunately, doctors choose your medication but don’t pay for it and you pay for your medication with no say in choosing it. 
  • While a  lack of transparency in drug pricing is a problem, the sheer number of prescriptions Americans fill is also a problem, resulting in an estimated $200 billion in unnecessary and improper medication use each year. 
  • Specialty medications and biologics continue to drive the high cost of prescription medications. 
  • Pharmacy benefit managers use rebates to negotiate drug prices and reduce costs for insurance companies, employers, and government agencies, but consumer interests are not represented.
  • Lobbyists for pharmaceutical companies and other political maneuvering block attempts to import drugs from other countries. 
  • Medicare Part D has its hands tied by the non-interference clause and cannot negotiate with drug manufacturers. Private insurers also feel the effects of this policy. 

Pharmaceutical Companies Get Up To 20 Years To Market Their Products With Zero Competition

Patents and drug exclusivity protection, sometimes lasting up to 20 years or more, give drug manufacturers time to market their products without competition. 

The premise behind patents is that pharmaceutical companies need time to sell their products without competition in order to recoup their innovation and research expenses. 

The problem is that drug manufacturers take advantage of these protections and extend them for as long as possible. Drug pricing can only decrease in a free and competitive market. 

How Patents and Exclusivity Protection Protect High Prescription Prices

Patents

The patent and trademark office can grant patents at any stage of the drug development process and provide 20 years of protection. It is also possible for a single drug to amass a  slew of patents and exclusivity protections, making them untouchable to competitors for decades.  

Market Exclusivity

Market exclusivity refers to the FDA’s ability to grant exclusive marketing rights following drug approval. Exclusivity is the primary factor that allows drug manufacturers to set their prices so high. With no competition, there is no incentive to lower drug prices. 

The goal of market exclusivity is to encourage drug innovation by shielding a new drug from generic competition for a set period of time. Under current law, FDA-approved chemically based drug manufacturers have the right to sell their products without competition for five to seven years. The more complex biologic drugs are protected for 12 years. 

Tactics Drug Companies use to Extend their Patent Protection

As patent protection expires, companies use a variety of business and legal strategies to retain price protections. 

Some of these practices include: 

  • Evergreening: filing for new patents on secondary drug features to extend their patent beyond 20 years. Seventy-eight percent of drugs for which new patents are filed with the FDA are already on the market. Almost 40% of all drugs have added patents to create market barriers to competition.  Over 70% of the top 100 best-selling drugs have had their patent extended once, and nearly 50% have had it extended more than once. 

AstraZeneca received a second patent for Omeprazole (Prilosec), a different form (isomer) of its drug, despite the fact that there was no evidence of a clinical difference. Thus, Nexium was born. It sold for $4 per pill, a 600% markup over over-the-counter omeprazole. Consequently, the Pennsylvania Employees Benefit Trust Fund filed a class-action lawsuit against AstraZeneca for unfair and deceptive trade practices. 

  • Product hopping: shifting consumer attention away from a product whose patent is about to expire and toward one that is not by making minor changes to the medication that make it not equivalent to any generic competition. The change can be as inconsequential as switching from a tablet to a capsule. Sometimes, the older product is taken off the market. Drug obsolescence is a strategy for maintaining a pipeline of new drugs that have been granted exclusivity.
  • Patent thickets: applying for multiple patents on the same product to prevent generics from entering the market. Enbrel, a medication developed in 1992 to treat inflammatory conditions such as rheumatoid arthritis, carries over 100 patents valid through 2029. The drug costs nearly $70,000 per year. Patent extensions for Humira, Enbrel, Keytruda, Revlimid, and Imbruvica, five of the top 10 best-selling drugs in the U.S. have led to over $500 billion in additional net sales. 
  • Pay for delay settlements: when the company producing the brand-name drug pays generic manufacturers to stay out of the market. 

Paragraph IV of the Hatch-Waxman Act grants the first generic drug manufacturer 180 days of generic market exclusivity after they show a brand-name manufacturer’s patent is invalid. Brand manufacturers can then counter-sue. When they counter-sue, they are granted an additional 30 months of exclusivity. 

One brand-name drug manufacturer and a single generic firm could agree to launch the generic months or even years into the future. This strategy would block any other generic manufacturer from entering the market. All it takes is for the brand-name drug manufacturer to pay off the generic manufacturer, a so-called reverse payment. 

Drug Manufacturers Have Complete Control Over Prescription Drug Prices

The Food and Drug Administration regulates the drug development process, but has no control over pricing. Outside of the U.S., governments negotiate drug prices with pharmaceutical companies.

Foreign governments weigh the added value of new drugs before deciding whether they are even worth bringing to market. If they determine a drug is more effective than anything else on the market, they will set a price their health insurance companies will pay. 

In the U.S., pharmaceutical companies determine their own prices and they bring any drug that is deemed safe and effective to market. This strategy leads to more medication options for consumers and a higher profit for investors, but at a much higher cost for consumers. 

When Gleevec, an anti-leukemia drug, was released in 2001, it cost $4,540 per month of treatment. After 15 years on the market, it cost $8,500 per month in the United States, $4,500 per month in Germany, and $3,300 per month in France. 

While innovation may have a price, there is no economic or rational reason a drug that is 20 years old should cost double in the U.S. 

Prescription Prices Are Not Readily Available To Doctors At The Point Of Care

Another reason consumer costs for prescriptions are high is that prescribers prefer to use medications they are most familiar with, even when lower-cost alternatives are available.

As an example, when researchers sent a questionnaire to 137 randomly selected physicians in Ohio, they found that physicians were motivated to consider prices when prescribing. However, they lacked the necessary information to price prescriptions and frequently made inaccurate assumptions. 

According to another study, only 31% of physician estimates of drug costs were within 20-25% of the true drug cost. The median estimate deviated from the true cost by 243%. 

Prescription pricing in the U.S. is complicated and constantly changing. However, changes may be coming that will make prescription pricing more transparent and accessible. By January 1, 2021, each Part D plan must implement one or more Real Time Benefit Tools (RTBT) that are capable of integrating with at least one of your doctor’s ePrescribing or electronic health record (EHR) systems. 

Another new Medicare rule requires companies that offer Medicare Part D prescription drug plans to offer enrollees real-time pricing information starting on January 1, 2023. This change will empower seniors with the information they need to compare out-of-pocket costs for various prescription drugs. 

As an example of the potential benefits of price transparency, prescribers who used CVS Health’s real-time pharmacy benefit information saved patients an average of $130 for each prescription they switched to a lower-cost option. According to the company, prescribers moved patients to a clinically suitable alternative 40% of the time. As these results show, pricing transparency can have a major impact on patient prescription prices.

Over-prescribing Is Also A Problem

Americans are said to have a love affair with prescription medications. Over half of Americans regularly take prescription medication. Those who take prescription medications take an average of four drugs.

The higher cost is not the only concern with polypharmacy (taking five or more medications). Taking more prescription medications is associated with increased side effects, dangerous drug interactions, non-adherence to treatment plans, and cognitive and physical decline.  Prescribing inappropriate medication to older adults is associated with increased hospitalizations and costs each patient more than $450 per year. 

Each year, adverse drug reactions account for:

  • Over 3.5 million physician office visits
  • An estimated 1 million emergency department visits
  • Approximately 125,000 hospital admissions

A combination of the culture in America, an increasingly harried healthcare system, and direct-to-consumer marketing has led to the perception that a prescription medication is the best way to address most health concerns. 

Specialty Drugs And Biologics Drive Higher Prescription Prices

The pharmaceutical industry is shifting its focus to specialty drugs and biologics. Specialty drugs usually require special handling, ongoing monitoring, and administration in a healthcare setting. These medications are used to treat cancer, rheumatoid arthritis, HIV, and multiple sclerosis, along with a range of other conditions. 

For some chronic conditions, a year of treatment with a specialty drug can exceed $100,000. The average monthly cost of a specialty drug is $4,500. Specialty drugs account for about 17% of an average employer’s overall pharmacy costs and are expected to increase to between 21% and 24% over the next three years. 

The decreasing costs associated with blockbuster drugs coming off patent have masked the skyrocketing costs of specialty drugs, keeping overall pharmacy cost increases to about 5% per year. But the savings are only temporary, according to Dr. Randy Vogenberg, at the Institute for Integrated Healthcare. 

Rebates are another way for pharma companies to protect their markets while keeping prices high

Drug manufacturers set the list price (wholesale acquisition cost). They sell their products to wholesalers who set an average wholesale price (AWP) which is the WAC plus around 20%. Wholesalers then distribute the drugs to pharmacies that set the usual and customary prices. 

If you have insurance, pharmacies charge you a copay and your insurance company covers the rest. Other pricing options include a cash price, a discounted price with coupons, a co-insurance price or free with a manufacturer coupon. 

Pharmacy benefit managers (PBMs) mediate the process. Their goal is to drive down drug prices for large employers, insurance companies, and government agencies, so they negotiate with pharmaceutical companies for rebates. 

To understand how this process works, it is important to know the roles of the six key stakeholders in the pharmaceutical drug supply chain. 

  • Pharmaceutical manufacturer: Develops, produces, and markets the drug
  • Wholesaler: Acts as a go between the pharmaceutical manufacturer and the pharmacy
  • Pharmacy: Dispenses prescriptions
  • Pharmacy benefit manager: Intermediary between the pharmacy and the health insurer who develops and maintains formularies and negotiates rebates and discounts
  • Health insurer: Private or Medicare Part D plans that provide insurance to patients
  • Patient: purchases the prescriptions

Brand manufacturers pay rebates to pharmacy benefit managers who negotiate prescription drug prices and formulary placement with pharmaceutical companies on behalf of health insurers, companies, and government agencies. 

The pharmaceutical company is willing to pay rebates to get moved to a better tier on the formulary. Formularies are lists of prescription medications that categorize them as preferred or non-preferred. Typically, formularies are divided into tiers. Each tier represents a different level of copay or coinsurance. Tiers determine how much you pay and how much the insurance company pays. 

Pharmaceutical companies want to be on the tier with the lowest copay cost to patients to increase sales.  As in any market, rebates are designed to shift purchasing volume toward that drug by refunding part of the purchase price to the buyer. By moving to a lower tier, it is possible for brand-name medications to have a cheaper copay than generics. 

Rebates are paid after a patient fills a prescription for a medication. The final price the health plan pays is considered a trade secret. The secrecy behind rebates makes price transparency impossible. 

Rebates affect patients in two ways. Rebates determine whether a brand-name drug is available on the formulary. And rebates keep patient out-of-pocket costs high because coinsurance costs are based on the pre-rebate cost of the drug. 

Rebates provide incentives to health insurers and pharmacy benefit managers to place high-price brand name prescriptions on formularies as preferred medications, which means you, the consumer, pay higher coinsurance. 

Rebates on brand-name drugs lower insurer costs and, therefore, premiums, but not patient out-of-pocket costs. You pay the same copay and a higher coinsurance (the percentage you pay after you have met the deductible). None of the savings trickle down to you, the consumer.

Private insurers are not the only ones involved in manipulating drug prices for consumers using rebates. The safe-harbor provision allows rebates to be paid through Medicare Part D without violating federal anti-kickback laws. Until this provision is removed, fair competition between manufacturers and price transparency is impossible. 

No, You Cannot Legally Import Drugs Into The U.S. 

Just as frustrating, it is illegal to buy and import prescription drugs from foreign countries, even Canada, where you could purchase prescription medications at half the cost.

The FDA’s reasoning for not allowing private citizens to import prescription drugs is that a drug produced and marketed in a foreign country may not be approved for use and sale in the U.S. In addition, it may be counterfeit and unsafe. 

Section 804 of the Food, Drug, and Cosmetics Act states that drugs can be imported from Canada by drug wholesalers or American pharmacists if they pose no additional risk to the public’s health and safety and result in a significant reduction in cost to the American consumer. 

This final rule is the subject of a lawsuit filed by Pharmaceutical Research and Manufacturers of America and other parties. 

Recently, the FDA passed a final rule that makes it legal for pharmaceutical companies to import their own drugs to bypass existing contracts with insurers or pharmacy benefit managers that prohibit the drug manufacturer from lowering its prices. So essentially, it is legal for pharmaceutical companies to import drugs to compete against themselves!


Medicare Part D Plans Have No Negotiating Power For Drugs In Six Protected Classes

While the Affordable Care Act has increased access to medications, drug prices have skyrocketed. If payers such as Medicare could negotiate lower prices, it would help offset the exorbitant drug prices protected by exclusivity and patent protection. 

The Centers for Medicare and Medicaid Services (CMS) established six protected classes of medications for which all 996 Medicare Part D plans must cover. Of the drugs in these classes, 143 are brand-name. 

  • Anticonvulsants (anti-seizure medications)
  • Antidepressants
  • Antineoplastics (anticancer medications) 
  • Antipsychotics
  • Antiretrovirals (commonly used for treating HIV/AIDS)
  • Immunosuppressants 

The reasoning here was that regardless of the cost, American citizens enrolled in Medicare Part D who need prescriptions in any of these six classes would have access. 

This requirement does not consider how effective the drug is. Medicare and other government programs cannot refuse to cover these medications. If they could, there might be some pressure to bring down drug costs. 

Medicaid drug prices are mandated by law to be at the lower end of the discounted price range or the lowest price that a payer can negotiate. However, this is not the case for Medicare Part D. The non-interference clause prohibits the Health and Human Services (HHS) Secretary from negotiating with pharmaceutical companies on drug prices. Instead, prescription drug plans negotiate with manufacturers and then compete for enrollees. This means that the government can have no direct role in negotiating or setting drug prices for Medicare Part D. 

This policy may change if H.R. 3  (the Elijah E. Cummings Lower Drug Costs Now Act) is passed. If this law passes, the government could negotiate prices for at least 24 single-source brand name drugs in 2024 and 50 in 2025 and beyond. These drugs would be selected from the 125 drugs with the highest net Medicare Part D spending. 

Actuaries predict that this law would save Medicare Part D enrollees $117 billion between 2020 and 2029. Since H.R. 3 would also apply to those with private insurance, they would save an estimated $54 billion between 2020 and 2029. 

It Doesn’t Have To Be This Way; The Department Of Veterans Affairs Can Negotiate

The Department of Veterans Affairs, unlike Medicare,  negotiates directly with drug manufacturers on drug prices. As a result, it pays on average between 56% and 63% of the prices paid under Medicare Part D. 

In 2016, California Proposition 61 proposed a referendum prohibiting state agencies from paying more for prescription drugs than the U.S. Department of Veterans Affairs. Over $128.28 million was raised in support and opposition to the referendum. Opponents of the bill raised $109.1 million—the top ten donors were pharmaceutical companies or their supporters.

As you can see, it is very difficult for any law that supports regulating drug prices to get any traction before lobbyists stall its progress or it is blocked by lawsuits.

Changes May Be Coming

In November 2020, the U.S. Department of Health and Human Services (HHS) of the Inspector General released a final rule stating that Medicare Part D prescription drug plan sponsors and their pharmacy benefit managers are no longer protected from liability under the discount safe harbor, which makes it possible for rebates to be paid under Medicare Part D. 

This rule was slated to take effect on January 1, 2022, but has been delayed until at least January 1, 2023, due to a lawsuit filed by The Pharmaceutical Care Management Association.

A new safe harbor rule allows discounts to be passed directly from manufacturers to patients at the point of sale. The new rule is expected to reduce prescription costs for consumers, increase price transparency, and create incentives for manufacturers to lower prices.

The prescription market is not like a consumer market, where demand falls when the price increases too much. Patients cannot defer buying prescriptions until the price of medications falls. 

Tactics such as evergreening, packet thickets, pay-for-delay settlements, and product-hopping protect brand-name manufacturers from normal market forces that control pricing. In addition, behind-the-scenes strategies such as rebates and jockeying to be on a preferred tier of a formulary make price transparency impossible. 

Until pharmaceutical companies are forced to compete in an open market, like other manufacturers, they have no incentive to control prices and no government agency has the power to make them do so. 

How You Can Fight Back Against the High Costs of Prescription Drugs

You may feel powerless against the drug manufacturers and their pricing strategies. But you are not. There are several avenues for you to explore to lower your drug costs. Of course, there is the well-known advice to always shop around for a lower price and buy generic when possible.  But there are also medication discount cards, patient assistance programs (PAPs), nonprofits, and manufacturer coupons. These strategies often make it cheaper to get your prescriptions filled without using your insurance benefits. 

As options increase for consumers to self-pay for prescriptions, it can feel a little overwhelming. We are here to help you navigate the consumer side of prescription pricing. 

Always Shop Around for Lower Prices 

Imagine you need a prescription medication filled. You met with your physician, discussed your medical diagnosis and treatment options, and decided on a generic medication from your insurance drug formulary. You are at the pharmacy. Suppose the pharmacist knows it would be cheaper for you to purchase your medication without using your insurance, but they cannot provide this helpful, cost-saving advice. 

A gag clause prevents many pharmacists from informing customers when there are less expensive options available. Some pharmacists are gagged by their contracts with pharmacy benefit managers (PBMs). PBMs manage the drug component of your health insurance plan. They determine how much you pay out-of-pocket for your prescription copay. Sometimes, this cost is higher than if you purchased the drug without insurance. It would be helpful for you to know when this is the case.

Most states are attempting to ban gag clauses to increase transparency in drug pricing. In the meantime, it is essential to be a savvy shopper and know how you can decrease your prescription costs. 

Generic Drugs

Generic drugs must meet the same quality and performance standards as brand-name drugs. They must have the same active ingredient, strength, dosage form, and administration route as the brand-name prescription. 

Generic drugs may differ from brand names in size, shape, and color but must prove to the U.S. FDA that the drug is bioequivalent to the brand-name drug. The generic drug manufacturer must also provide relevant clinical data as well as assurance that their manufacturing facilities adhere to good manufacturing practices.

When the market is opened to generic manufacturers, the average prescription price drops between 38% and  48% for physician-administered drugs and by 25% for oral medications. 

For example, the price of Lipitor, a cholesterol-lowering statin, has fallen by 95 % since it became generic in 2011. 

There has been a trend toward an increasing generic drug share of the market. Brand-name drugs have dropped from 39.9% of all prescriptions dispensed in the United States in 2005 to 9.8% in 2019. This is a trend in the right direction!

Both supply and demand factors may play a role in this trend. On the supply side, several blockbuster drugs have gone off-patent. On the demand side, expanded access to prescription drug coverage through changes in Medicare coverage and the Affordable Care Act have increased the total number of prescriptions filled. In addition, private payers have structured formularies into tiers to encourage the use of generics by offering them at lower copays. 

Medication Discount Cards 

Companies, such as GoodRx, offer prescription discount cards that often provide lower medication prices at local pharmacies than you can get using your insurance. They achieve these lower prices by negotiating with a network of PBMs and pharmacy owners to purchase medications in bulk. 

Prescription discount cards can help you save money on prescription drugs, but they are not insurance. The discount cards can be used whether or not you have insurance. 

The company offering the prescription discount card may receive a referral fee from the pharmacy and charge a monthly membership fee. The pharmacies benefit from increased traffic in their stores and increased sales to consumers who might not otherwise fill their prescriptions. The downside for pharmacies is that they must accept the lower price. Ultimately, the consumer often gets much lower prescription prices, sometimes up to 80% off the retail price of their medication. 

Most medication discount cards are free to use. The drawback—there are numerous programs in place, and the discounts are constantly changing. Finding the best prices takes time and effort.  

The steps: 

  • Choose your medication savings program
  • Choose your local pharmacy with the lowest price
  • Show your savings card when picking up your prescription
  • Get the discounted rate

Who can benefit from using a medication discount card? Anyone who: 

  • Does not have insurance
  • Has not met their insurance deductible
  • Has a prescribed medication that is not covered by their insurance
  • Has a high copay
  • Is in the Medicare Part D donut hole

The only disadvantage of using medication discount cards is that prescription costs do not count toward your plan deductible. 

Who is not eligible to use medication discount cards?

Using pharmacy discount cards when using Medicare Part D coverage is prohibited by a federal anti-kickback statute. According to the law, customers may not be given coupons or discounts for any items or services covered by the federal healthcare program. 

Medication discount cards, on the other hand, can be used as long as they are not used in conjunction with Medicare Part D or Medicaid. 

Patient Financial Assistance Programs

Patient Assistance Programs (PAPs) are programs offered by pharmaceutical companies to provide free or discounted medications to patients who cannot afford them. Each program has its own set of eligibility requirements. These criteria may include:

  • proof of citizenship 
  • proof that if you have insurance, it does not cover your medication
  • income level
  • number of family members in the household
  • medical need

Many programs require a doctor’s input into the application. Unfortunately, the application process is frequently overly complicated, but there is help available if you need it.   

Nonprofits 

Nonprofit programs are charitable organizations that can assist with prescription costs. There are usually eligibility requirements, such as meeting diagnostic and treatment criteria and being under an income cap. These programs may consider your living and medical expenses when determining your eligibility. 

Manufacturer Coupons

Manufacturers issue manufacturer-sponsored prescription drug coupons to defray the cost of specific brand-name prescription medications. These coupons can be used to reduce your copay if you have insurance or if you do not have insurance to decrease your medication costs until you reach the manufacturer’s specified maximum out-of-pocket savings. 

Other Ideas

Over time, you may also have developed prescription savings strategies such as pill splitting, using mail-order prescription sources, or asking your physician to write for 90 day or even 365 days of prescription at once. 

If you are prescribed a medication, ask if there are any generics available, check the prices on multiple strengths, and ask your doctor if there are any other dosing options. 

These strategies do not work for all prescriptions but keep a running list of possible ways to maximize your savings. 

Final Thoughts

According to the Centers for Medicare and Medicaid Services (CMS), national health spending is expected to increase at an annual rate of 5.4% between 2019 and 2028, reaching $6.2 trillion by 2028. This figure, however, does not take into account the additional healthcare burden imposed by COVID-19.

Patents, exclusivity rights, the inability of government health plans to negotiate costs or limit the drugs available through their plans, and pharmaceutical companies’ assertion that high costs are necessary to fund drug research and development all contribute to higher drug prices.

As an informed consumer you can play an active role in lowering your prescription costs. Prescription discount cards, manufacturer coupons, patient assistance programs, price comparison tools, and checking prices in big box stores can all help you significantly reduce your prescription drug costs.

Special Enrollment Period Extended Through May 15th

The executive order directs the Secretary of HHS to consider establishing a special enrollment period through HealthCare.gov that will run from February 15 to May 15, 2021. It cites provisions of the ACA governing the marketplaces and federal regulations that allow a special enrollment for “exceptional circumstances”—here, these circumstances are the ongoing COVID-19 pandemic.

The Health and Human Services Announcement

HHS immediately announced the HealthCare.gov special enrollment period in a press release and fact sheet. The special enrollment period will be available to all qualifying consumers who submit a new application or want to update an existing application (i.e., for current enrollees). State-based marketplaces can, but do not have to, allow for a similar special enrollment period, although some states have already announced that they will do so. Coverage is prospective, meaning it will begin on the first day of the month after a consumer enrolls through HealthCare.gov. Current enrollees will need to revise their current application to claim the special enrollment period and receive an updated eligibility determination. HHS’s fact sheet makes clear that applicants should face no heightened application questions or verification requirements (such as documentation to show they qualify for a special enrollment period).

$50 Million Committed To Outreach and Education

At the same time, HHS announced that it would commit $50 million to outreach and education to raise awareness of the special enrollment period. This is incredibly important since awareness of the marketplaces remains low, and the HealthCare.gov advertising and marketing budget was cut by 90 percent under the Trump administration. HHS can easily pull these funds from the user fees that insurers pay for the use of HealthCare.gov. A recent analysis from the Kaiser Family Foundation found that HHS currently has more than $1 billion in unused federal user fee revenue. These funds could be tapped to invest in HealthCare.gov marketing and advertising and the navigator program, as well as make other consumer-friendly improvements to HealthCare.gov and the call center. (Under the partial final payment rule for 2022, HHS would further cut the user fee for HealthCare.gov.)

How States Reacted

All but one state-based marketplaces provided broad COVID-19 special enrollment periods—leading, in some states, to record-high enrollment—and many invested in additional outreach and marketing. But the Trump administration refused to do the same for HealthCare.gov, despite widespread support from stakeholders such as insurer associationsgig economy companies (such as Postmates and Instacart), members of Congress, governors and attorneys general, and a broad coalition of more than 200 organizations. The refusal to allow a special enrollment period led to a lawsuit, although the new executive order and HHS action in response may lead to settlement or dismissal of that lawsuit.

How This Could Help You

A special enrollment period, paired with an aggressive advertising and marketing campaign, could have a significant impact. An analysis by the Kaiser Family Foundation suggests that nearly 9 million currently uninsured people could enroll in free or subsidized coverage through HealthCare.gov. Of these, 4 million would qualify for a no-premium bronze plan. An additional 6 million uninsured people could qualify to purchase unsubsidized ACA coverage if they can afford it. The executive order notes that people of color—Black, Latino, and Native American people, in particular—are more likely to be uninsured even while being disproportionately affected by the COVID-19 pandemic.

This broad special enrollment period is likely to be good for the marketplace risk pools rather than lead to adverse selection. State-based marketplaces have indicated that their COVID-19 special enrollment periods helped bring in younger enrollees. And the same Kaiser Family Foundation analysis notes that the remaining uninsured who could qualify for free or low-premium coverage are more likely to be young adults. For instance, 39 percent of the 4 million uninsured people who qualify for a no-premium bronze plans are between the ages of 19 and 34.

Read more here

The Best HealthShare Companies Reviewed

What’s Different About A Health Sharing Program

Health Sharing programs are 501(c) 3 non-profit organizations that help their members share their money to pay for each other’s medical bills. These programs are not insurance programs in the traditional sense, but offer an affordable alternative to cover your medical expenses. Plans on the Healthcare.gov marketplace often come with high premiums and deductibles, making a HealthShare plan a great option for people without pre-existing conditions.

Read more about how HealthShare plans are different from traditional insurance in our guide on How To Compare HealtShare Plans To The Health Insurance Marketplace.

The Best, Most Affordable HealthShare Companies Reviewed

HealthSharing companies became very popular after the Affordable Care Act was passed because they offered an affordable alternative to marketplace plans. However, picking the right organization is important. You want to make sure that the company is reputable, long standing and, most importantly, regularly pay the claims of their members.

Our Top Pick: Medi-Share

  • One of the oldest, most reputable HealthShare companies in the U.S.
  • Great track record of paying out claims
  • Offers a provider network with 900K providers nationwide
  • Is stable and dependable with a member network with over 400,000 people
  • Includes free telemedicine, and offers 6 months of savings on Rx
  • Get paid back quickly: 90% of claims are paid within 30 days
  • There is no maximum for the healthcare bill you can claim
  • Negotiates with doctors and providers directly, like traditional insurance
  • Has limitations on pre-existing conditions
  • Must make a statement of faith to be able to join
Monthly Share (monthly bill)Monthly share amount is based on age, marital status and location
Initial Unshareable (amount you pay before coverage kicks in)There are seven plan options:$1,000 $1,750$3,000$4,250$5,500$8,000$10,500

Enroll in a Medi-Share health plan today

Runner Up: Christian Healthcare Ministries

  • Like Medi-Share, Christian Healthcare Ministries is one of the oldest, most reputable HealthShare in the U.S.
  • Offers three tiers of plan pricing—Gold, Silver and Bronze—which range in the Initial Unshareable (think of it like a deductible with normal insurance) of $500, $1,000 or $5,000
  • Limits the amount you can claim to $125,000 per illness
  • However, you can sign up for an additional coverage which covers needs above $1 million
  • There are limitations to covering pre-existing conditions
Monthly Share (monthly bill)Gold: $172 per personSilver: $118 per personBronze: $78 per person
Initial Unshareable (amount you pay before coverage kicks in)Gold: $500Silver: $1,000Bronze: $5,000

Samaritan Ministries

  • Offers three programs, Samaritan Given, Samaritan Classic and Samaritan Basic. Given is an app-based program that allows you to manage your plan through your phone. Classic is a less tech savvy way to still get medical coverage traditionally
  • Samaritan Given plans include Annual Household Portions (deductibles) at $1,000, $2,000 and $5,000
  • Does not cover pre-existing conditions
  • Requires a strict faith commitment and regular church attendance
  • Charges a $200 on-time startup fee
  • Requires you to negotiate with medical providers directly
Monthly Share (monthly bill)Samaritan Basic: $227 Samaritan Classic: $555 
Initial Unshareable (amount you pay before coverage kicks in)Samaritan Basic: $1,500 Samaritan Classic: $300 

The Best Sites To Enroll In Health Insurance Reviewed

If you’re someone who doesn’t get health insurance through their employer, you’ve probably signed up for an Affordable Care Act (ACA) plan through healthcare.gov. But did you know that there are other, Healthcare.gov certified, partner sites that allow you to enroll as well?

Why Use An ACA Certified Partner Site?

These sites were started after the Healthcare.gov marketplace was launched to address the slow, clunky and confusing experience. A certified partner site offers the exact same plans and the exact same prices as Healthcare.gov, but help you make a more informed decision. They’re faster too—enrolling in health insurance through HealthSherpa takes only 15 minutes on average.

These sites also offer free features like dedicated expert call and chat support, so you can get help if you get stuck or have questions about your options.

Ready to enroll?

The Best Healthcare.gov Partner Sites

Our Top Pick: Health Sherpa

  • Their process helps you find the most affordable plan based on your specific family, financial situation and healthcare needs
  • Offers dedicated call and chat support, completely free
  • Maximize your savings, subsidies and tax credits. 8 out of 10 people qualify
  • Breaks confusing insurance jargon down into plain english so it’s easier to understand what you get
  • Make it easy to see which plans your doctors and hospitals accept, and if your prescription drugs are covered
  • Personalizes your plan shopping experience based on the insurance options that best fit your needs
  • 100% free service

Use HealthSherpa to find coverage

GetInsured.com

  • Helps you qualify for tax credits based on your income
  • Let’s you compare plans with tax credits vs full priced plans
  • Allows you to shop for and filter plans based on plan type and feature
  • An effective site experience, but suffers on smartphones
  • Does not offer 24/7 live support
  • 100% free service

GoHealth

  • Offers phone support and enrollment
  • Does not offer a fully online enrollment process
  • Specializes in Medicare plans and Annual Enrollment Period
  • 100% free service

Healthcare.gov

  • Was the original online healthcare marketplace
  • Makes it difficult to shop plans, see your savings or enroll without creating an account
  • Website is not mobile friendly, hard to use on a smartphone
  • Offers information and resources on official policy of the healthcare marketplace, like the 10 essential consumer benefits
  • Allows you to enroll completely online
  • Offers a 1-800 hotline for questions
  • 100% free service

Open Enrollment 2021: Key Dates, Deadlines And Questions

Between November and December, every year, is when people are allowed to sign up for a health insurance plan for the first time or make changes to their existing plan. We’ve collected the key dates, deadlines and answered the most common questions to make this year’s open enrollment as seamless as possible.

Key Dates And Deadlines For Healthcare Marketplaces During Open Enrollment 2021

When does open enrollment start?November 15th
When is the deadline to enroll?
For MinnesotaDec 22, 2020
For ColoradoJan, 15 2021
For NevadaJan, 15 2021
For PennsylvaniaJan, 15 2021
For WashingtonJan, 15 2021
For Massachusetts Jan, 23 2021
For Rhode IslandJan, 23 2021
For CaliforniaJan 31, 2021
For District of ColumbiaJan 31, 2021
For New JerseyJan 31, 2021
For New YorkJan 31, 2021
For all other statesDecember 15, 2020
When does coverage begin?January 1, 2020 (or after you enroll if you live in a state that’s extended open enrollment)

Important: You Have To Enroll Before Your State’s Deadline

If you don’t act by December 15 (or your state’s extended deadline), you can’t get 2021 coverage unless you qualify for a Special Enrollment Period. If you haven’t already, find a plan today with Health Sherpa.


Reminder: The 10 Essential Benefits That Are The Same For All Marketplace Plans Found On Health Sherpa

  • Ambulatory patient services (outpatient care you get without being admitted to a hospital)
  • Emergency services
  • Hospitalization (like surgery and overnight stays)
  • Pregnancy, maternity, and newborn care (both before and after birth)
  • Mental health and substance use disorder services, including behavioral health treatment (this includes counseling and psychotherapy)
  • Prescription drugs
  • Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)
  • Laboratory services
  • Preventive and wellness services and chronic disease management
  • Pediatric services, including oral and vision care (but adult dental and vision coverage aren’t essential health benefits)

Find the plan that’s right for you 

Answers To The Most Common Open Enrollment Questions

Where Is The Best Place To Shop For Plans?

You can shop available plans to find the best coverage using Health Sherpa. Enrolling on HealthSherpa only takes an average of 15 minutes. If you’re stumped on which plan to choose, you can talk to an expert who will walk you through the process. Call (844) 215-9595 to for help enrolling or to get answers to any questions you may have.

HealthSherpa is a certified enrollment partner of the government and their enrollment process is straightforward and simple. They offer all of the same plans at the exact same prices as HealthCare.gov, the government’s enrollment site. The difference is they offer a smarter enrollment process, a website that’s easier to use, and help you to maximize your subsidies and savings. 

Who is eligible to shop during Open Enrollment?

Not sure if you’re eligible to shop the Marketplace for an Obamacare plan? Good news: you probably are!

If you are a U.S. citizen, national or legal resident of the United States who currently resides in the U.S., you’re qualified to shop the Marketplace. This includes green card holders, refugees, asylees, and individuals with non-immigrant status who have a valid worker visa. 

The only exceptions? If you’re currently enrolled in Medicare or currently incarcerated. 

What If My Employer Offers Insurance?

If your employer offers ACA-compliant health insurance and you choose to opt-out of it and purchase your own Obamacare plan, you usually won’t be eligible for any subsidies and will need to pay full price for your monthly premiums. Because of this, if you have access to health insurance coverage through your employer, we recommend you utilize that instead of the Marketplace, unless your employer insurance costs more than 9.78% of your household income.

Will I Have To Pay A Fine If I Don’t Have Health Insurance In 2021?

Congress repealed the penalty for having health insurance in 2018. That means in most states, you won’t have to pay a fine if you go without coverage in 2021. 

However, the following states passed their own individual mandates, you may have to pay a penalty.

Which States Have A Penalty If I Don’t Have Health Insurance?

  • California
  • Massachusetts
  • New Jersey
  • Rhode Island
  • Washington D.C.

What do I need when I’m ready to enroll?

You’ll need some basic information on-hand to get started with the Open Enrollment process. 

First, you’ll need to provide information about your household, including household size (including anyone you claim on your tax return). For each of these people, you’ll need some basic information like birth dates, home addresses, and social security numbers.

Additionally, you’ll need information about your best estimate for your 2021 income, information on how you file your taxes if you have a spouse, information about your sources of income, and policy numbers from any current health insurance plans. 

You should also ask yourself these questions:

  • What type of plan is it?  
  • Health Maintenance Organization (HMO) – does not have out of network benefits
  • Preferred Provider Organization (PPO) – has in and out of network benefits
  • Health Saving Account Plans (HSA) – lets you save for medical expenses on a tax deferred basis
  • Are my current doctors and specialists and hospitals covered (in-network)?
  • Are my current medications covered (in-network)?
  • What will I be paying including premiums and out of pocket costs? 
  • Are any of my medical needs excluded? 

What if I already have a plan from last year?

If you had Marketplace health insurance in 2020, you will be automatically re-enrolled in that plan for next year if that plan is still being offered. If that plan is no longer available, you’ll be enrolled in an “equivalent” plan. Although that might sound like the easiest way to approach OEP, it isn’t necessarily your best option. In fact, people who who shop and switch plans save an average of 38% on their monthly premiums.

Most insurers are expanding their coverage areas this year, which means there will be more plans available to you. Without shopping to compare what plans, and savings, are available to you this year, your premium payments may increase substantially. Plan details can change from year to year, too, meaning that prescription coverage, provider networks, and coverage benefits could change even if you keep the same plan. By shopping the Marketplace, you’ll find out what kinds of available plans might best suit your needs for the coming year, and what cost savings you will be eligible for with those plans. It only takes a few minutes to shop and compare your options, and this can keep you from paying more later. 

Am I Eligible For Subsidies, Cost-sharing Reductions, And Tax Credits?

Many Americans are eligible to save on their health insurance costs as a result of the Affordable Care Act. No matter where you live, if you earn between 100 – 400% of the Federal Poverty Level (determined by the federal government) and aren’t eligible for Medicaid, you will qualify for a premium tax credit that will help lower your premium costs. By 2020’s FPL numbers, this meant that a family of four whose combined household income was between $26,200 and $104,800 would qualify for a premium tax credit. 

Depending on your income, you may also qualify for Cost Sharing Reductions (CSR), which are special savings built-in to Silver-level Marketplace plans for people who earn between 100 and 250% of the federal poverty limit. These CSRs limit and reduce out-of-pocket costs like copays and deductibles. 

Remember that if you are married and do not file taxes jointly with your spouse, you will not be eligible for any subsidies or CSRs in the Marketplace. 

High medication costs? Here’s how to potentially save thousands during open enrollment

Open Enrollment Is Your Biggest Chance To Reset Your Coverage

If you’re someone who has a chronic condition and has to pay for bills and prescriptions related to treating your condition, open enrollment is your biggest chance this year to get the coverage that’s right for you. By right coverage, we don’t mean the cheapest plan option. We mean finding the insider tips and tricks to cover your expenses while still saving money. 

In this guide, we’re going to walk through an Uncovered member’s story, Carol’s story, and show you how she saved $8,000 a year on her health coverage by making smart choices during open enrollment and the steps you should be taking to save like she did. 

To protect her privacy, Carol’s name has been changed, but the details of her story are true.

How Carol Saved $8k a Year. The 4 Things She Did Differently: 

For comparison sake, this example is based on 2020 numbers.

For starters, Carol has multiple chronic conditions that she needs health insurance to help her pay for.  She is self-employed, which means she was using the Affordable Care Act healthcare exchange to buy her own insurance to cover medical expenses. 

The problem is, her insurance was breaking the bank and barely covering her needs. So she started by sitting down to do a little homework to see what her situation was.

Carol’s Health Situation

  • Carol is female, 46, single, with multiple comorbidities
  • She has rheumatoid arthritis and high blood pressure 
  • Her BMI is 29

1. Where She Started: Getting An Accurate View Of Her Financial Situation

She started by putting together a rough picture of how much she expected her medical costs to be without any insurance coverage.

Her total income$63,000 per year
Her after tax income$4,147.95
Her monthly medication cost for Humira$5,500 per month
Her monthly medication cost for Amlodipine$20 per month
She anticipated 1 primary care visit per year$120 per visit
She anticipated 2 visits with a specialist per year$480 ($240 per visit)
Her total estimated medical cost without insurance for the year$66,840

2. What She Did Next: Shopped the market for her options

What were Carols’ insurance options?  Due to her preexisting conditions, the only programs that cover pre-existing conditions are ACA compliant plans.  Therefore, she will need to go through her state’s healthcare insurance exchange, ideally through Health Sherpa to maximize her subsidies.

Health Sherpa will automatically calculate the availability of any subsidies based on Carols’ income and dependent status. Unfortunately, Carol did not qualify for any subsidies.

Health Sherpa will allow you to see all plans available and allows you to quickly sort to find the lowest premium plan or the lowest total out of pocket plan.  

[insert image from Health Sherpa]

Here’s a tip: if you don’t anticipate using your insurance, take the lowest premium plan. But if you’re in a health situation like Carol, you’ll need to spend more time to find the right plan.

This is the best deal on health insurance Carol could find:

Lowest Monthly Premium Plan Cost
$13,142 per year

The big problem with her options:

  • That’s extremely expensive compared to Carols household budget
  • The significant contributor to the annual cost was Carol’s Humira

3. She Didn’t Give Up, And Found A Solution For Her Biggest Problem

But Carol didn’t give up. She realized that her biggest expense was her Humira prescription—so she turned to prescription patient assistance programs (PAP programs) and used RXHope.com to search for any PAP programs for Humira. She found two that would turn out to be game changers.

  • She found a PAP program she could apply to through her physician that might reduce her costs. 
  • It was based on her income and on high insurance out of pocket costs.
  • The direct manufacturer program was called Humira Complete.  
  • It reduced her costs to as low as $5/mo.  
  • It required her to have insurance that was not federally or state funded, she must have insurance that covers Humira (both options she considered did).  
  • Humira would reimburse the insurance company and pay her portion of the deductible associated with the Humira costs.  

Note: you must make sure the insurance coverage you are considering does not exclude such programs. You will need to contact the insurance company directly and inquire.  The enrollment firms will not be able to help at his detail level.

4. How Her Hard Work Saved Her Thousands

Carol revisited her health plan options and confirmed directly with her chosen insurance company that they would accept the Humira complete card.

Lowest Monthly Premium Plan Cost
Original cost per year$13,142
Cost after PAP program$4,272
Total Carol Saved$7,360

Carol’s health profile and understanding her costs allowed her to pick the most appropriate plan for her budget.  Her additional effort in reducing her drug cost significantly reduced her total expenses to a manageable level.  It was worth the extra work!

Can You Do The Same Thing? 

Step 1: Start By Completing Your Health Profile

Do what Carol did to start. Fill out what you think your medical expenses will be in the coming year. Here’s how to do that:

  • Do you expect to have the same, less or a greater number of services for this coming year?
  • Based on the costs for those services last year and the number you predict for next year, add up what you anticipate spending in the coming year.  
  • If you anticipate needing additional care, get an idea for what that might cost using Fair Health 

Now you are prepared to shop for health insurance coverage.

Step 2: Find your biggest recurring expense. 

The next step is to see if you have a major recurring expense each year. If you have a chronic condition you take medication for, it’s probably that prescription. If you can identify where you’re spending the most before hitting your deductible, you can find tactics to reduce it.

Step 3: Find an insider way to save on it

You’ll want to look for cost assistance prescription programs.  Search for PAP programs on RXHope.com, they can help you find significant discounts or no cost branded drugs that do not have an alternative generic.  By doing so you may reduce a significant portion of your out of pocket insurance expenses which may influence what plan you pick.  

Then you should always want to look into drug discount cards to see if you can reduce costs on other drugs you are using. Try using our drug discount search engine.

Step 4: Re-evaluate your health plan options

Now that you have an idea of the real coverage you need, go back and look at those plans again. Maybe you don’t need the most expensive option that looks like it offers the best care. Maybe you don’t need to find the cheapest monthly premium option. Either way, comparing your homework to the plans will help you find the best deal.

Step 5: Make an informed decision

Always ask the potential insurance company you’re considering these questions to uncover if you in the right place:

  • Are preexisting conditions covered
  • Are the benefits unlimited?
  • Does the plan cover the ten essential coverages? (see attached)
  • Am I guaranteed renewal?

Note: The exchange provides a summary of benefits and plan details on every plan offered.  Make sure you read them. 

If you’re willing to put in the hard work, you have a choice. That choice could mean savings of thousands of dollars—which is worth the extra effort!

Open Enrollment 2021: Health Sharing Plans Compared To Health Insurance Marketplace

If you’re enrolling in a health insurance plan for 2021, marketplaces like healthcare.gov or HealthSherpa are ideal for people who don’t get their insurance through their employer and who have pre-existing conditions or higher health needs.

But what if you’re healthy? What if you don’t have high expenses related to chronic conditions? What if you still want health coverage without having to pay hundreds every month for a plan that has a $2,000, $3,000, or $4,000 deductible?

If you do not have pre-existing medical conditions, you should consider and compare Health sharing programs, otherwise known as Christian care plans. 

The Alternative To ACA Plans That Can Save You Up To 50% Per Month On Healthcare

What Are Health Sharing Plans?

Health Sharing programs are 501(c) 3 non-profit organizations that help their members share their money to pay for each other’s medical bills. These programs are not insurance programs in the traditional sense, but they do cover your medical expenses and can save you hundreds of dollars on premiums and deductibles compared to ACA plans. Read Nat’s story to see Medishare in action.

What You Get And How They Work

Cheaper “monthly premiums” – Health sharing plans don’t have monthly deductibles, instead they require monthly share payments that are based on your age, health and number of people in your household. The average single family household saves $128 per month with Medishare. A family of 3+ saves $590 per month on average.

Coverage for unexpected medical bills – A health sharing plan covers you for unplanned, costly medical expenses like a broken bone or getting diagnosed with a disease like cancer

A PPO Network – Most Health Sharing plans offer a Preferred Provider Organization (PPO) where members can choose in-network doctors to receive discounted medical care

Coverage for prescriptions – Prescriptions can be covered but are limited to six (6) months of treatment for each medical condition over the lifetime of the Member.

What’s Different Compared To An ACA Plan

Since health sharing programs are not health insurance, they aren’t mandated to cover the 10 essential benefits that all ACA plans are required to cover. Because of this, health sharing plans mostly focus on providing assistance for unexpected, larger medical expenses. These are the key differences between a health sharing plan and typical health insurance.

They require a commitment to certain Christian Tenets –  Because most health sharing organizations are Christian faith organizations, they do not cover health needs that fall outside the tenets of the religion. Things like alcohol abuse, illegal drug use and birth control related costs are not covered. 

They can exclude pre-existing conditions – If you have preexisting conditions, they can choose not to accept your member applications since they are not governed by the affordable care act.

Share in the financial health burdens of other members – Your monthly share payments go directly to helping other members pay for their medical bills.

Ask for your medical history – As a part of the application process, most health shares ask you to complete a medical history questionnaire before your application is approved.

They may limit medical coverage levels – health share plans usually do not offer unlimited medical coverage. They will cover you up until a point, usually $1 million, after which you have to start paying the medical bills.

Do You Have To Be Christian To Have Christian Care?

In order to qualify to become a member, you have to abide by the tenets of the health share. This usually includes making a statement of faith when you sign up. Beyond that, members are asked to agree to live by biblical standards and to support one another’s burdens. However, there aren’t explicit requirements that applicants have to belong to a church to become members.

When considering this type of plan always ask the following:

  1. What type of plan is it HMO (do not have out of network benefits), PPO ( has in and out of network benefits), and Health Saving Account Plans  (HSA) ( let you save for medical expenses on a tax deferred basis).
  2. Are my current providers covered?
  3. Are my current medications covered?
  4. Are any of my treatments or services excluded?
    1. To shortcut reading the whole summary plan description document, go to the exclusion section first.  Then you service is not specifically excluded read the entire document.

Comparing ACA Plans To A Health Share

So how do Health Share plans stack up to a comparable ACA plan? Below is an example of the comparison for someone who’s 29 years old and doesn’t have health issues.

ACA PlanHealth Share
Premium Cost$222$242
Deductible$8,550$3,000
What insurance pays
before deductible is met
$0$0
Visit to a
Primary Care Provider
$30$35
Visit to a
specialist
Deductible must be
met first
$35
TelemedicineNot coveredFree
PrescriptionsDeductible must be
met first, then 100%
6 months covered
after deductible has been met
ER VisitDeductible must be
met first, then 100%
$200 per visit
Inpatient Hospital
Visit
Deductible must be
met first, then 100%
Deductible must be
met first, then 100%
Mental HealthDeductible must be
met first, then 100%
6 months psychotherapy covered
PregnancyDeductible must be
met first, then 100%
Coverage limited to tenet guidelines
In Network
Coverage
Varies by plan990,000 nationwide providers
Out Of Network CoverageVaries by planPlan pays 70%, you pay 30%

Reviewed: Which Health Share Company Is Right For You

Trust is important when it comes to finding a health share organization that fits your needs. When the affordable care act was passed, so-called “health share” companies started to pop up as a way to skirt ACA requirements and offer sub-standard coverage. These newer organizations were also notorious for being slow to pay for benefits or even not paying at all.

The Top 3 Health Share Organizations

These are our top three picks for HealthShare organizations. Click to read our full review.

  1. Medi-share – Our #1 pick
  1. Christian Healthcare Ministries
  1. Samaritan Ministries 

Open Enrollment 2021: What You Need To Know This Year.

Has it been a year already?  Healthcare open enrollment is approaching faster this year, than any other year, and choosing a health plan is very important.  A lot has changed since last year because of COVID-19 and it’s critical that you have some form of health insurance for the coming year.  

Biggest 2021 Open Enrollment Updates

  1. Insurance Rate Increases Are Going To Be Lower Than Previous Years

Good news! From an insurance standpoint, the average rate increases appear to be lower than previous years.  

  1. There Are More Insurance Providers in The Marketplace

Another upside is the number of health insurance carriers offering plans is increasing. On average, marketplaces are offering 4.5 health insurance carrier options per state up from 3.5 in 2018 and 4.0 in 2019. That means more options for you to choose from! 

  1. You May Qualify for Subsidies If You Recently Lost Your Job or Took a Pay Cut

If you are one of the fortunate ones that have not been financially impacted by the COVID-19 pandemic (still employed with no loss of income), open enrollment will be relatively similar to last year, but with some more options. If you have lost your job or have had significant income reductions due to the COVID-19 economy and have a preexisting condition, Affordable Care Act (ACA) subsidies may provide some financial relief.  

The Basics of Affordable Care Act (ACA) for 2021

What ACA Plans Cover

Remember, ACA compliant health insurance plans covers:

Remember that ACA plans are the best options for people with pre-existing conditions or if you qualify for subsidies. If that’s not you, check out our post on alternative health plans.

Qualifying For Subsidies

ACA endorsed enrollment systems will calculate whether or not you qualify for subsidies. Uncovered’s partnership with Health Sherpa will help calculate your potential subsides when you enter your estimated income for 2021 (Bonus! Through Health Sherpa, you’ll be able to calculate your subsidies in just minutes vs the typical 25+ minutes through healthcare.gov.) The calculator will determine if you qualify for a health insurance subsidy and how much that subsidy will be or if you qualify for Medicaid, which in many states requires little or no monthly premiums*

To illustrate how powerful these subsidies can be, we calculated a Michigan family of four making $63,000 a year. They lost a third of their income during the pandemic, reducing their family income to $41,500.  When reapplying for a health plan, they became eligible for subsidies which reduced their monthly premiums from $1,100 to $108 per month!  

*Note: if your estimated 2021 income ends up higher by year end the government has the right to recoup apportion or all of the granted subsidies difference.  The 2021 results will vary due to new 2021 premium and plan offerings.

Depending on Where you Live, The Process of Signing Up for ACA Will Vary. 

For most states, you can begin the ACA sign up process directly through Health Sherpa to find the plan that’s right for you. However, if you live in one of the states in the list below, you must sign up for ACA through a state-specific process, since these states are “State-based Marketplaces” or SBM’s. 

Find your state below and click the link to start the process of signing up for ACA:  

STATESTATE-BASED MARKETPLACE
CALIFORNIAhttps://www.coveredca.com/
COLORADOhttps://connectforhealthco.com/
CONNECTICUThttps://www.accesshealthct.com/
DISTRICT OF COLUMBIAhttps://dchealthlink.com/
IDAHOhttps://www.yourhealthidaho.org/
MARYLANDhttps://www.marylandhealthconnection.gov/
MASSACHUSETTShttps://www.mass.gov/topics/health-care
MINNESOTAhttps://www.mnsure.org/
NEVADAhttps://www.nevadahealthlink.com/
NEW JERSEYhttps://nj.gov/getcoverednj/
NEW YORKhttps://nystateofhealth.ny.gov/
PENNSYLVANIAhttps://pennie.com/
RHODE ISLANDhttps://healthsourceri.com/
VERMONThttps://portal.healthconnect.vermont.gov/
WASHINGTONhttps://www.wahealthplanfinder.org/
ALL OTHER STATES https://www.healthsherpa.com/

For information about the difference between State-Based Marketplaces, State-based Marketplace-Federal Platform and Federally-facilitated Marketplace, see below:   

  • State-based Marketplace (SBM): States running a State-based Marketplace are responsible for performing all marketplace functions for the individual market. Consumers in these states apply for and enroll in coverage through marketplace websites established and maintained by the states.
  • State-based Marketplace-Federal Platform (SBM-FP): These states are considered to have a State-based Marketplace, and are responsible for performing all marketplace functions for the individual market, except that the state will rely on the federal Healthcare.gov website for eligibility and enrollment functions. Consumers in these states apply for and enroll in coverage through Healthcare.gov.
  • Federally-facilitated Marketplace (FFM): In a Federally-facilitated Marketplace, HHS performs all Marketplace functions. Consumers in FFM states apply for and enroll in coverage through Healthcare.gov.

Read our full review of the best sites to enroll in marketplace health plans.

Questions To Ask Yourself Before Picking A Plan

 Before choosing a plan, make sure to ask yourself these questions: 

  • What type of plan is it?  
  • Health Maintenance Organization (HMO) – does not have out of network benefits
  • Preferred Provider Organization (PPO) – has in and out of network benefits
  • Health Saving Account Plans (HSA) – lets you save for medical expenses on a tax deferred basis
  • Are my current doctors and specialists and hospitals covered (in-network)?
  • Are my current medications covered (in-network)?
  • What will I be paying including premiums and out of pocket costs? 
  • Are any of my medical needs excluded? 

If you are concerned about being able to pay for the higher out of pocket costs, there are other actions you can take: 

  • Talk to your doctors and providers about payment plans
  • Ask the hospital for financial assistance and/or check with patient access foundations (e.g. Patient Advocate Foundation) and disease state foundations (e.g. American Cancer Society). They may all be able to assists with your bills
  • Instead of avoiding getting medical treatment because of financial strain, consider opening an extra credit card for medical expenses that can cover up-front costs, that you can pay off later. 

The Best Telemedicine Companies Compared

Telehealth or telemedicine use is on the rise since the COVD-19 pandemic hit. And, ever since the CDC recommended the benefits of telemedicine, the amount of companies providing online doctor services has exploded.

But not all telemedicine companies are created equal. While most offer board certified doctors, the quality of the service and app can be huge, plus the pricing can change dramatically. If you’re looking for an appointment with an online doctor, there tons of choices, making it difficult to find the right answer for you.

We’ve reviewed the best telemedicine services to make it easier for you to find the right online doctor.

Best For Immediate Access To Virtual Doctors For Urgent Needs

Doctor on Demand

Cost per consultation: $75

  • Available 24/7/365
  • Services available with and without insurance
  • Can provide prescriptions
  • Visits with doctors, psychologists, or psychiatrists
  • Treatment for hundreds of issues 

Teladoc

Cost: $75 for everyday care without insurance

  • Available 24/7/365
  • Provided by your insurance plan, your employer, or other organization
  • Can provide prescriptions
  • Medical services include ear infections and sinus problems
  • Visits have no time limit

MDLive

Cost: $82 per urgent care visit

  • Virtual visits any time, day or night, and holidays
  • Short-term prescription refills
  • Treatment for over 50 non-emergency conditions like ear pain or allergies
  • Mental health support with licensed therapists or psychiatrists
  • Dermatology services

Amwell

Cost to download: Free

  • $79 or less for urgent care visits
  • $99 starting cost for online therapy visits
  • $269 initial online psychiatry visit, follow-up visit starting at $99
  • Available 24/7/365
  • Accepts several major insurance plans

Best For Mental Health And Access To Therapists

Talkspace

Cost: $65/week for just messaging, $99/week for messaging and 4 live videos

  • Covered by insurance
  • Matched with therapists in your state
  • Send therapists unlimited messages
  • Therapy available for adults, teens, and couples
  • Can get medication prescribed

Cerebral

Cost of medication and therapy plan: $35/week for the first month

  • Find licensed therapists and counselors online
  • Schedule live sessions or chat using the messenger tool
  • Meet in a secure, virtual room
  • Schedule short, mini-sessions or long, thorough sessions
  • Can get medication prescribed

Best For People On Tight Budgets Or If You Don’t Have Insurance

Sesame

Per average visit: $30

  • Book virtual visits with vetted doctors in your area without needing insurance for same day care
  • Chat with local licensed doctors near you
  • Get prescription refills, same day care
  • Book follow up, in-person appointments through the app

HealthTap

Cost: $10/month for unlimited monthly visits

  • Make unlimited calls or video chats to doctors 24/7
  • Get doctor-ordered prescriptions sent to your pharmacy or home
  • Order lab tests and see results on HealthTap
  • Get access to HealthTap’s massive library of member-asked, doctor-answered questions on any health-related topic or symptom

Best To Check Symptoms Or Text With Doctors

Just Answer

Cost: $18-$46 for a monthly subscription

  • Connect one on one in a text chat with 
  • Get near instant answers to your questions
  • No call or video chat support and Just Answer cannot provide prescriptions

Talkspace

Cost: $65/week for just messaging, $99/week for messaging and 4 live videos

  • Covered by insurance
  • Matched with therapists in your state
  • Send therapists unlimited messages
  • Therapy available for adults, teens, and couples
  • Can get medication prescribed

KHealth

Cost: $9/month or $19 for a one time visit

  • Message with a doctor
  • Use their smart AI to check your symptoms
  • Get prescribed medication over text
  • Therapy available for adults, teens, and couples
  • Can get medication prescribed

Coronavirus Is Stressing Me Out

As coronavirus and the encouragement for social isolation continue, stress is taking its toll with job-loss, loneliness and worry are surging.  As reported in in a post in the Wall Street Journal on May 25, 2020, Andrea Peterson reports that more are turning to medications; like anti-anxiety anti-depressant medications and sleep aids which have risen during the pandemic.

Tina Fey’s wisdom on the impact from stress was highlighted in her book Bossypants,

I was a little excited but mostly blorft. "Blorft" is an adjective I just made up that means 'Completely overwhelmed but proceeding as if everything is fine and reacting to the stress with the torpor of a possum.' I have been blorft every day for the past seven years.

Peterson, continues, prescriptions for anti-anxiety medications, like Klonopin and Ativan, rose 10.2% in March 2020 and prescriptions for antidepressants, like Prozac and Lexapro, rose 9.2% in the same period.

Circumstances including health concerns, social isolation, childcare, at home schooling and job losses are eroding the sense of calm and taking a toll on people’s well-being. In fact, the American Psychological Association shared that was parents with children under 18, 46% rated their average stress level related to the pandemic as 8, 9 or 10 on a 10-point scale, according to a survey the released May 21.  

As reported in the Washington Post on May 26, 2020, the Census bureau recently released a study suggesting 1/3 of all Americans now show signs of anxiety depression or both. Most would think the most of those experiencing these symptoms of fear would be the most at risk, those over the age of 80. Not true, this study found that younger people, specifically younger Americans under the age of 30, are more upset and challenged by the Coronavirus Anxiety and Depression. 

What can we do, you and me, to address the anxiety and depression and the fears that seem to be our new normal. 

Here’s some thoughts

ONE - pay attention to what you are listening to ... turn off the news and turn on your favorite Pandora playlist. If you need an example, I listen to a soft jazz and a reggae playlist. Both help me to exhale and that feels much better than the churn of my stomach after a daily dose of the news. 

TWO - smile ... yes smile. My kundalini teacher Jae Dev Sing suggests when our body is engaged our mind will follow. So, take some time each day to smile ... especially with those you love and care for, be it on a phone call or in person, even if you are socially distanced. 

Until then, I am Doc Frank your friendly psychologist. 

Frank Wood, PHD

Dr. Frank Wood is a Licensed Psychologist  and the creator of Thriving with Stress, an innovative training program designed to leverage stress – in the workplace, in relationships and with life.

As a speaker, author and trainer on stress, Dr. Frank has applied all of his expertise and experience in developing The Thriving with Stress program; a program that clients refer to as a "game changer" and a “program that is turning the tables on stress.”

COVID-19 And Health Insurance: Everything You Need To Know

Uncovered, in partnership with HealthSherpa, is committed to keeping you up-to -date on what your health insurance covers for COVD19, and what to do if you lose your health insurance. We wanted you to see what HealthSherpa has published on questions you may have – as well as a question direct from our community.

Right now, many Americans are practicing social distancing to help “flatten the curve” of the transmission of coronavirus. But at the same time, they are also seeking information on what to do should they contract COVID-19. 

If you are concerned you may have COVID-19, here’s what to know about how your insurance works when it comes to testing in light of the expanded Centers for Disease Control (CDC) testing guidelines. 

If you don’t have health insurance, enter your zip code below to search for plans and prices below. If you lost your insurance recently, you may qualify for a Special Enrollment Period (SEP), and several states have announced SEPs for all residents due to COVID-19.



Does insurance cover testing and treatment?

Per the CDC, testing for coronavirus—the novel virus that causes COVID-19—is now available in all 50 states. There are currently a total of 75,000 lab kits “cumulatively” available for public labs and more are hoped to be available soon. Private companies like Lab Corp and Quest Diagnostics will be providing the majority of testing, though. And many Americans may be wondering what this means in terms of what their insurance may cover. 

The Trump administration has announced that testing for COVID-19 has been designated as an Essential Health Benefit (EHB), meaning that testing must be covered by all ACA- compliant plans. This means if you are enrolled in a Marketplace plan, your insurance company will cover COVID-19 testing. 

COVID-19 testing is also covered by Medicare and in most cases by Medicaid.

If you have coverage through an employer, whether COVID-19 testing is covered depends on the size of your employer. If you are employed by a company with fewer than 50 full time employees, COVID-19 testing will in most cases be covered. If you are employed by a larger company, whether COVID-19 testing is covered is determined by your employer; you should contact your benefits department for more information. 

In addition, many health insurance companies have announced that the test will come with a $0 co-pay, at no cost to the patient. 

You can check out https://www.ahip.org/health-insurance-providers-respond-to-coronavirus-covid-19/ which is being maintained and updated by the official member organization of the insurance industry to see how your insurance company is handling fees associated with coronavirus testing. 

Many insurance plans will also be covering telemedicine services should Americans wish to speak with a doctor at home through web-based conferencing, thus allowing them to continue to socially distance. Contact your health plan to learn about their telemedicine options. 

Any treatment you need for COVID-19 will be covered by your insurance in the same way as any other similar treatment or hospitalization, although some insurance companies are waiving certain copays you may have to pay for COVID-19 treatment. Once again, you can consult this list from America’s Health Insurance Plans (AHIP) to learn more about the details of coverage. 

Depending on the type of plan you have, the kind of coverage it provides, and your specific insurance carrier, the specifics of cost-sharing and benefits can vary when it comes to costs you may need to incur as a result of testing and treatment. Important to keep in mind is that while co-pays may be waived or COVID-19 testing, this may not apply for all other tests, treatments, or doctor’s visits associated with the virus, including hospitalization. Which means depending on the kind of health insurance plan you have, you may need to meet your deductible before full coverage kicks in for your treatment, including whatever benefits you may have for in-patient hospital care. 



What are the risks of being uninsured during the coronavirus outbreak? 

If you are uninsured, then you will need to pay for the cost of coronavirus testing and any treatment associated with COVID-19 yourself. The out-of-pocket costs for testing without insurance can range from approximately $500 at a doctor’s office to approximately $1000+ in a hospital setting. 

In 2018, 27.9 million nonelderly Americans were uninsured in the United States. Most uninsured people are in low-income families, with families of color disproportionately represented among uninsured Americans. 

Can I still get health insurance?

To see your options, contact us at HERE.

Outside of Open Enrollment, you can typically only enroll in health coverage if you have a qualifying life event—for example, losing your health coverage within the last 60 days.

From our Uncovered community: What if I lose my employer-based coverage?  What if my income changes and I can’t afford coverage?  What if I don’t currently have coverage?

If you’re concerned about losing your health insurance due to job status change (full time to part-time or job loss), consider these options: If your employer has over 20 employees ask your employer about your COBRA option.  You can continue under your current plan for up to 18 months but will be required to pay the full monthly premium.  Currently your employer contributes between 75-80% of the monthly cost. Loss of health insurance due to a job status change within the last 60 days is deemed a qualifying life event which entitles you to enroll in any ACA health plan. If this is you (you have lost your insurance and you want to enroll in an ACA plan) – and you live in California, Colorado, Connecticut, DC, Massachusetts, Maryland, Minnesota, Nevada, New York, Rhode Island, Vermont or Washington – click on your state link listed below and you can see how to enroll now.If this is you (you have lost your insurance and you want to enroll in an ACA plan) – and you live in a state other than those listed in the point above, CLICK HERE and we will connect you to enrollment options. The resulting reduction in earnings from a job loss may qualify you for government health insurance subsidies on qualified ACA plans or for Medicaid coverage which varies by state but requires minimal premium contributions.If you don’t currently have health insurance and haven’t experienced a job status change, many states—currently California, Colorado, Connecticut, DC, Massachusetts, Maryland, Nevada, New York, and Rhode Island—have opened up Special Enrollment Periods to help people without health coverage get insured during the coronavirus pandemic. The federal government has not yet BUT is considering opening a Special Enrollment Period as well. So if you live in one of the states not listed in the point above, stay tuned – you may have a chance to enroll at a future date before the October, 2020 open enrollment period. We will keep you apprised of if and when that happens.

If you have lost your health insurance and want to enroll in a new ACA healthcare plan, and you live in one of the states below, click on the state in which you live. Otherwise, CLICK HERE.

If your state appears on the list below, you won’t use HealthCare.gov. You’ll use your state’s website to enroll in individual/family or small business health coverage, or both.
California
Colorado
Connecticut
District of Columbia
Idaho
Maryland
Massachusetts
Minnesota
Nevada
New York
Rhode Island
Vermont
Washington  

If you are currently uninsured, don’t forget that you can apply to see if you or anyone in your family may qualify for Medicaid or CHIP at any time—you don’t need a qualifying event to apply.

How does ACA insurance compare to short-term insurance during the coronavirus outbreak?

While coronavirus testing is now an Essential Health Benefit (EHB) and thus qualified for no co-pay coverage, EHBs only apply to ACA-regulated plans. Which means that EHBs do not apply to short-term health insurance

Short-term plans typically do not cover pre-existing conditions, preventive care, emergency services, mental health care, prescription drugs and maternity care. If you have a short-term health insurance plan, know that you may need to pay out-of-pocket for any coronavirus testing or coronavirus-related hospitalization you may need for treatment. 

Only plans that are regulated by the Affordable Care Act, such as those available on the Health Insurance Marketplace, contain no-cost Essential Health Benefits. 


Enter your zipcode to search for marketplace plans and prices.


Can I apply for Medicaid or CHIP?

You can apply for Medicaid or CHIP year-round. You don’t need a qualifying event.

What is Medicaid?

Medicaid is a program jointly funded by the federal government and the states to provide health insurance to low-income Americans. Medicaid eligibility is determined based on income level. Adults, children, pregnant women, the elderly, and people with disabilities can all become Medicaid recipients. Medicaid covers one in four children, 21 percent of all low-income adults, and 60 percent of nursing home residents in the United States at this time. 

While details of Medicaid programs and benefits vary by states, federal law does require that all Medicaid programs cover a certain set of “mandatory benefits.” These include inpatient and outpatient hospital services, nursing facility services, home health services, physician services, and laboratory and x-ray services. 

What is CHIP?

The Children’s Health Insurance Program (CHIP) provides low-cost health insurance to children up to age 19 to children whose families earn too much to qualify for Medicaid in their state, but do not earn enough to be able to afford private insurance. In some states, CHIP also covers pregnant women. Every state runs and offers their own CHIP insurance program for children. 

While you can apply for CHIP at any time, and do not have to wait for the annual Open Enrollment Period (OEP), in 15 states, children may have to be uninsured for up to 90 days before becoming eligible to enroll in CHIP. 

Each state has different guidelines in terms of income eligibility and eligibility standards. 46 states plus the District of Columbia make CHIP eligible for children whose families earn up to or above 200% of the Federal Poverty Level (FPL). That translates to $50,200 for a family of four. 24 of these states offer CHIP eligibility to children in families who earn 250% or more of the Federal Poverty Level, or $64,750 for a family of four. 

While details of CHIP benefits vary slightly by state, federal law guarantees that CHIP programs everywhere must provide comprehensive coverage, including:

  • Routine check-ups
  • Immunizations
  • Doctor visits
  • Prescriptions
  • Dental and vision care
  • Inpatient and outpatient hospital care
  • Laboratory and x-ray services
  • Emergency services

Why Every Mom Needs A Telemedicine App On Her Phone

Megan Weddle works for First Stop Health, a company that specializes in bringing telemedicine to consumers, so it’s no surprise she’s a fan of technology itself. Her reason, though, is beyond professional—it’s personal.

Telemedicine helped Megan discover her twelve-year-old-son Brady—whom she thought was dealing with a simple stomach flu—was actually facing appendicitis.

Not the Stomach Flu

It all started when Megan decided to take her eleven and twelve year old children on a flight to the west coast to visit relatives. It was the first long flight for the kids, and her son Brady complained a little about his stomach hurting on the flight. They thought it was just upset from the cookies on the plane.

“The number one thing the kids wanted to do when we got to California was go to In-N-Out Burger,” Megan says. “After visiting the Hollywood sign, my son looked at me and said, ‘I need to find a bathroom NOW.’”

The flight, the burger, the time difference . . . Megan knew it could have been anything.

They hopped in the car on the way to Santa Monica, and Megan wondered several times if she’d need to pull over for Brady, who was still struggling with stomach issues in the back seat.

An hour later, as she was handing her card over to the receptionist at the hotel, Brady ran straight for the bathroom. He came out a few minutes later, saying he’d gotten sick.

As the rest of the family went to the pool—with everyone agreeing it was best to stay away from what was surely the stomach flu—Megan considered her options.

Where Megan Turned Instead Of Racing To Urgent Care

“It was close to the time an urgent care would be closing. Then, I thought to myself, I am going to call First Stop Health. I work for a telemedicine company. This is what it’s for: avoiding unnecessary visits to the ER or the doctor.’”

Megan picked up the phone and dialed. Although she could have opted for a video visit, she chose the phone option that time. Even though Brady wasn’t registered with First Stop Health, she was able to use her info and give his age, medical history, and presenting symptoms. She told the nurse that she thought it was the stomach flu and likely needed some anti-vomiting medication.

The Doctor’s Time Saving Diagnosis

When the doctor got on the line, he indicated he wanted her son to do a balance test, just to rule out anything more serious than the stomach flu.

“He told me to have Brady jump on one foot. I thought it was ridiculous—he’d been jumping all day, running around, before he started to feel bad. Brady refused to jump, though. Then the doctor said he hated to be the bearer of bad news, but my son was presenting with appendicitis.”

The doctor gave her information for two hospitals near where they were staying. They went immediately to the ER, where the doctor gave the same balancing test—which Brady failed.

His appendix was about to burst, and he needed emergency surgery.

Brady made it through the surgery just fine, but if his appendix had burst, there could have been serious complications. Megan credits First Stop for being a big reason why she got Brady to the hospital in time.

“The best part of this service is having access to a doctor 24/7. As a parent, sometimes you think you know it all. But, to be fair, we don’t. If Brady’s appendix would have ruptured, we would have been in California longer. Because we caught it and did the surgery right away, we only had to spend one night in the hospital. He bounced back.”

What’s Different About First Stop 

On top of being a quick way to talk to board certified doctors, First Stop has other benefits, too. The service costs just a couple of dollars every month for individuals, unlike other telemedicine services that charge up to $75 per call. 

First Stop can also be used by up to seven other family members, meaning the whole family can have instant access to care. 

A Good Call For Moms With Kids

In addition, using telemedicine can be uber-convenient and less risky to other members of the family who are not sick.

“Sometimes, you don’t want to drag your non-sick kids into a waiting room, which is a petri dish. There’s only so many times you can say, ‘don’t touch that.’ I know. I am a mom of four!”

In the end, telemedicine not only made the trip easier on Megan and her family, but it also could have saved Brady’s life. That’s a call that’s always worth it.

Saving $1,600 On A Knee Injury – How Kelly Pulled It Off

If you have a medical procedure coming up, do you feel like you’re limited to the doctors in your area and bound to pay whatever they charge? Think again. You can shop around.

Let’s take a look at how one woman did just that—and saved over $1,600 on the cost of an MRI in the process.

When Kelly Slater, a runner, injured her knee, she just knew it was a torn meniscus. Her doctor suspected the same and ordered an MRI to verify. 

The catch? 

Her insurance company said she needed to wait six weeks to get the MRI—and even worse, it looked like it was going to be expensive.

Limited Access To Healthcare Options

Kelly lives in lower Michigan in a rural area, so her hospital choices were limited. The local MRI option was going to cost around $2,000—$1,083 more than the national average of $917!

Because she had time—and at the insistence of a friend who just happened to write a book on being a consumer of healthcare —she opted to shop around.

“It never occurred to me to shop around before then,” Kelly said. “It’s kind of a one-pony show up here. You go to the place that’s available.”

Kelly said she considered paying cash to get a lower rate, but because she knew she’d need surgery and thus meet her deductible for the year, it was more cost-effective to find the cheapest route through her health insurance.

How To Find The Best MRI Cost

Kelly followed a step by step approach to research and shop for the best, most affordable care. Here’s how to do what Kelly did:

  1. Call the physician and ask for the procedure code. Note that there can be multiple codes for each type of procedure. For an MRI, for example, there are different codes for “with contrast” and “without contrast.” Be sure your doctor provides you with the code for the precise procedure you’re getting.
  2.  Call different facilities you’d like to price shop, ask for their facility code (or ICD10), and ask the medical billing department for their price based on the procedure code from your physician. See our list of healthcare transparency sites for resources to help you find and compare providers.
  3. Call the insurance company and give them the information: the procedure code, the facility code, and the quoted price—and have your insurance company confirm what you’ll owe.
  4. Make the decision that is most in line with what you want and need for your healthcare—and your bank account. You should also remember that most outpatient facilities offer payment programs, which can be a great fall back option.

Kelly’s Shopping Success Story

Ultimately, by using a simple online search to find facilities and then calling around to get the lowest price, Kelly found a facility that would do the MRI through her existing insurance for a price of $341—a savings of over $1,600. She scheduled the test for the exact day her six-week waiting period was up.

“Through this experience, I learned to shop around because the medical care that’s available to you isn’t always the cheapest. It pays to look for some competition,” Kelly said.

It’s important to note that the MRI Kelly received—the one that was $1,600 cheaper at another location—was a 2D MRI, not a 3D MRI. Both of these types of MRIs can generally be used to diagnose a meniscal tear with similar accuracy.

IMPORTANT NOTE: It’s critical to check with your doctor to see what kind of MRI you need in your situation, rather than go with the one that’s most convenient or cheapest.

“Here [at the local facility] I would’ve been paying for a fancier machine that I didn’t really need. My doctor didn’t care if the MRI was 2D or 3D. It definitely makes sense to do your research .”

Ultimately, the MRI confirmed what Kelly and her doctor had suspected, and she got the care she needed for her injured knee. She reports she is very glad to be back up and running!  

How Eric’s Proven Negotiation Tactic Saved Him $2,000 On A Colonoscopy

If you have a planned hospital need, you aren’t at the mercy of the billing department: if it makes sense for you, you can pay cash and save—sometimes up to 75 percent! In this article, we’ll look at how.

Here at Uncovered, we get it. All those tests, procedures, and surgeries are stressful enough in premise alone. Then, you factor in the cost, the fear of medical debt (and the fact that it can feel impossible to know how much you’ll owe ahead of time), and your stress level goes through the roof, right?

It doesn’t have to be like that. With a few calls and by asking the right questions, you can learn your all-in price. What was Eric’s big trick?

Paying upfront, in cash.

When it doesn’t make sense to pay in cash

Look at what kind of plan you have. If you have a full plan that covers preventative care, you’re safe. Or, if it’s early in the year and you have a low deductible that you know you will hit—and need to hit to account for more upcoming expenses during that calendar year—you’re also safe. Nothing to do. (Just make sure you stay in network!)

When it does make sense to pay in cash

If you have short-term insurance, it almost never covers preventative care, so it makes sense to find out the cash price. If you have a deductible you know you will not meet during the calendar year and are having a non-preventative procedure, it also makes sense to find out the cash price. You’ll be paying it in cash anyway, so why not pay less?

Here’s how to find out the cash price:

Step One: Call the surgery center or physician and say you’d like to negotiate.

Step Two: Ask who is involved in the procedure, what services you will receive, and get a breakdown of those costs. For example, for Eric’s colonoscopy, they broke it down for him all the way to the cost per polyp removal.

Step Three: Tell them you’d like to negotiate an all-in price to pay on the day of service.

Step Four: Save big money!

These Tips in Action

Eric Neuville is the perfect example of what to do when it comes to negotiating hospital bills. When his doctor referred him for a colonoscopy, he knew it wouldn’t be covered under his short-term medical insurance because his plan didn’t pay for preventative care at all. He also knew his deductible was high–$8,000—and that he wasn’t going to meet it.

Eric’s doctor told him he wasn’t sure how much the colonoscopy would cost. What he refers to as his “sort-of” insurance carrier also told him they didn’t know (and wouldn’t until the surgery center billed them). The common refrain was that the procedure had to be done for them to know—which, according to Eric, was ridiculous. And he would know, as a twenty-five year veteran of the insurance industry who ran product development for Anthem Blue Cross and Blue Shield.

Eric’s wife called the surgery center and asked for the all-in cash price on a colonoscopy. They broke it down for her: if they paid in full on the day of service, it would be $1000 cash, a savings of almost 70 percent.

The day of the surgery, Eric walked in and told the receptionist he was quoted a cash price of $1,000. He gave them two cards: his insurance card and his payment.

When the couple later got a bill with a “discounted” price of over $3,000 for the surgery, Eric had to remind them that he’d already paid—and that he hasn’t paid nearly that much.

It wasn’t the couple’s first time using the cash method to save. When Eric’s wife had a hip and knee replacement due to arthritis, they got another 75 percent discount by paying a quoted all-in price up front.

What Eric Has To Say About Negotiating

Eric is an advocate for healthcare consumerism not just when it involves his bank account.

“We need to be as active in our healthcare choices as we are when we make a choice about what television to buy next,” he says. “We have to challenge ourselves. I have zero patience for the ‘I have insurance, so I don’t have to worry about it’ mindset. That drives up costs for us all.”

Proven Health Insurance Advice For Open Enrollment

I spoke with M.C. Laubscher on his podcast, Cash Flow Ninja, recently about the things everyone should be thinking about when they’re making decisions about their healthcare. His listeners come to him all the time with questions about healthcare…”What should I do? How much should I be paying? How do I find better information to make smarter decisions?”

M.C.’s audience is filled with entrepreneurs and investors and the advice I have for them is perfect for anyone who is looking for individual insurance during open enrollment this fall. We talk through:

  • The difference between healthcare and insurance
  • What everyone should be doing during open enrollment to find the best insurance plan
  • How to manage healthcare costs

Listen to the full episode below

How To Choose The Best Health Insurance For 2020

Picking your health insurance plan for 2020 is an important decision you’ll be stuck with for the entire year. Which means it’s worth taking the time to do a little homework and make the pick that’s right for you.

Follow these seven steps to make sure your insurance plan fits your health needs and your budget.

1. Start With Your Health History

Make a list of how much you used your health insurance last year. The list needs to include physician office visits, prescriptions, diagnostic and lab work, and medical procedures.

2. Find Out What Plans Are Available To You

Identify the plans available to you, the amount of cov- erage they offer, and the amount of upfront dollars you will need to pay.

Use a chart like this to help you organize:

Plan 1Plan 2Plan 3
Premium (cost per month)


Deductible (amount you pay before
insurance kicks in)



Co-pays


Out of pocket charges


3. See How Each Plan Stacks Up Compared To Your Expected Medical Costs

Compare the costs of every health plan available to you. Don’t automatically exclude any, even those with a high deductible. Which plan costs you the least in total?

4. Find Out What Can You Afford Monthly

Can you handle your healthcare costs in one payment or, if not, how much you can afford monthly. For example, can your pocketbook sustain $694 in monthly costs, or $8,365 annually? Be realistic.

Tip: check out the Kaiser Foundation’s calculator for help with this.

5. See If Your Current Doctors And Hospitals Are In Network

If you go to an out-of-network provider, your copay, deductible, coinsurance, and out-of-pocket maximums will generally double. You’ll have to decide if that doctor/provider is worth it or be forced to find another doctor. 

6. See What’s Covered

  • Pregnancy
  • Hospitalization
  • Emergency services
  • Outpatient care
  • Mental health
  • Prescription drugs
  • Rehabilitation services
  • Lab services
  • Pediatric services
  • Preventative services

7. List the tax deferred mechanisms of each plan

Ask for and study all tax deferring or saving mechanisms available like premium-only plans, flexible spending accounts, health reimbursement accounts, and health savings accounts. These plans all allow you to save and use your dollars before income tax is applied, kind of like a 401K. These options are no brainers when they’re available to you since they increase the amount of money you have to pay for your health expenses.

 Remember, don’t overinsure by selecting the plan with the lowest out-of-pocket fea- tures, because it will have the highest premiums, which are non refundable. This checklist will give you a clear idea of the most cost-effective plan that meets your specific needs. 

You only have one chance a year to make the best choice, so do your homework!

Check out Health Sherpa to find and compare the best insurance plans for you.

Uncovered’s Top Healthcare Transparency Services | 2019

Healthcare transparency sites give you access to information that could help you make smarter decisions and save you thousands of dollars. But not all healthcare transparency sites are created equal. Below is our list of the top healthcare transparency websites for 2019.

Be Careful Who You Trust

Healthcare transparency sites are usually built on access to real, anonymized healthcare records that allow them to analyze cost, effectiveness and provide reviews. The only problem is, sometimes this data isn’t accurate, or the site just isn’t pulling from a large enough population to provide accurate information.

The Sites That Made Our List

We’ve reviewed each an every one of these sites to make sure they’re helpful and user friendly—but most importantly, that you can trust them. They’ve earned our stamp of approval as insiders and we think you should use them.

Reviews, Affiliation & Scheduling | Qualitative Sites

Reviews & Comparison

Reviews & Scheduling

Procedure Cost Predictors | Quantitative Sites

Cost estimator tools

Carrier cost estimator tools

Coupons And Saving Sites

Patient assistance programs

Rx Coupon Codes

EHR vendors

Even More Sites Are Coming

Healthcare price transparency is a growing trend—more and more people want to know what they’re going to pay when they visit the doctor or hospital. Everyday new sites are started to help people better understand the cost of healthcare. 

Bookmark this page. We’ll continue to update this guide as new sites become available. But most importantly, use these sites! The information they give you could save you hundreds or thousands of dollars.

From No Coverage to Affordable Coverage, with HealthShare

“It’s not technically insurance—even though it is. And I can’t speak for everyone, but from my experience, there are no downsides.”

That is the way Nat Comisar describes the HealthShare program he and his wife switched to after finding the traditional route—searching on the Healthcare Marketplace (Obamacare)—to be far too pricey.

Nat was no stranger to the world of insurance, either. In the past, he was the employer who provided healthcare to his employees. When he became self-employed, he figured he’d have no problem securing insurance. After all, he was a healthy 55-year old man with no preexisting conditions and on no medications.

Easy, right? 

Wrong.

To the best of his memory, the best deal he could find was going to cost him $680 a month with a $7200 deductible. Because he rarely had any reason to go to the doctor in the first place, that could have amounted to almost $16,000 annually for something he didn’t even use.

So, what was next for Nat? He made the same decision a lot of people in that situation do: he went without insurance for five years, finding it far cheaper to simply pay the fine when tax time came around.

When Nat’s wife went to search in the Healthcare Marketplace, her premium was more reasonable—at first. It started at around $270 per month. Then, it started steadily increasing, all for the exact same coverage. When it approached $500 per month, Nat’s wife made the same decision as her husband: she went without insurance for about a 18 months.

Discovering HealthShare

While out to lunch with a friend—a friend who had just happened to be writing a book at the time about how to take control of your healthcare and save money along the way—Nat learned of an option he had no idea was out there: HealthShare.

“The way I understand it, the HealthShare Market is the way insurance is supposed to be,” Nat says. “It’s a pool of individuals who are funding a contingency for one another for health concerns.”

HealthShare programs are religion-based. Many don’t require you to be a member of that particular religion, just that you are a person of faith. Remember—each program is different, so do your research wisely.

Nat did just that, focusing on three major HealthShare companies. He ultimately chose the one that seemed easiest to join and most organized—Solidarity HealthShare, a Catholic Organization.

Practically, Nat now pays $300 a month to cover both him and his wife. Collectively, they have a $1000 deductible. 

“We still don’t use any of our insurance dollars,” Nat says. “In this last year that we’ve been a part of this, I bet we’ve only spent about $400 towards our deductible. Still, it’s so worth it. A plus is that with this company, if I do get to a place where I need assistance, I can see who it comes from. I can also see where my contribution is being sent and send a message to them, if I want.”

To be eligible for this program, Nat had to pledge a few things: that he was a nonsmoker, did not use illicit drugs, and was a moderate drinker, if he drank at all. If he had any preexisting conditions (he didn’t), he’d have to declare them up front—but that would not make him ineligible for coverage. Instead, it would mean he could not be reimbursed in the first year of being in the pool, and only up to $25,000 annually the second and third years. For everyone—preexisting condition or not—there is a $1 million lifetime cap.* 

Nat’s plan sends him and his wife to annual checkups, both of which are covered. There is no pharmaceutical component to his plan, but that’s okay—there are discount cards to help with that.

Sometimes, when Nat does need to use his HealthShare—which, by the way, satisfies the legal requirement for having health coverage, saving him that annual tax penalty—receptionists give him a funny look. He says he’s used to explaining from there.

“I tell them, ‘It’s HealthShare, not insurance. You should be able to file it. If you can’t, just consider us a self-pay, and we’ll file it.’”

The Bigger Picture

Nat says in the beginning, he was curious about the extent of the religious component. 

“In the end, I’ve found it to be a Christian organization that is a big group of people supporting one another,” he says. “There’s not a profit motive.” 

In retrospect, Nat says he wishes he would have known about HealthShare sooner.

“Before, I had 350 employees in the restaurant business. Had something like this existed—or had I known it existed—I could’ve covered everyone at 100 percent, purchased supplemental insurance, and still not have to ask for their financial participation.” 

If someone who was in the business of providing health insurance didn’t know about this option, odds are that this is your first time learning about HealthShare, too. We want to be clear: this option is not for everyone, but if it turns out to be for you, you could be on the receiving end of some big savings.

*Remember that not all HealthShare programs are the same. For more information the company Nat and his wife decided to use, visit Solidaryhealthshare.org. To find the right option for you, visit HealthSharingPlans.com.

Overpaying for Your Prescriptions? Here’s Proof You Don’t Have To

Prescriptions are expensive, but you have more resources available to help you cut those costs down than you think. Here, we’ll look at how one man saved $422 a month on his medication by leveraging a Patient Assistance Program (PAP)–and how you can get similar results.

(Yes, you did read that correctly: $422 a month!)

No one is immune to the high prices and feeling of bureaucracy that can sometimes shroud the world of healthcare and big pharma—not even Scott Heiser, who literally wrote the book on the subject.

The difference is that Scott knew what to do—and, by being here, that means you can, too.

In the past, Scott was hospitalized with deep vein thrombosis (DVT) and subsequent pulmonary embolism—i.e., a blood clot in the lungs. Scott recalls that the whole thing was a shock, kind of a “freak incident.” He talked with the physicians, who said he needed to be on a blood thinner for a year. 

Together, they discussed options: there was Warfarin, an older and relatively inexpensive prescription, or Eliquis, a newer-generation drug that was more costly. Each drug—as is true for them all*—had pros and cons: Scott learned it was easier to control bleeding and coagulate more quickly with Warfarin, but he’d also to test his blood often. With Eliquis, he wouldn’t have to test his blood, and he’d have the convenience of only taking one pill a day. Although an uncontrolled bleed was not likely in his case, if he faced one, it would take him longer to coagulate.

Because Scott’s risk factors were low for needing quick coagulation—and taking into account he only needed to be on the precautionary medication for a year—he and his doctor decided Eliquis was the best choice.

The problem? It was $432 a month. Because Scott knew about PAPs to reduce consumer costs, though, he was able to get that cost down to $10 a month.

That’s that mega monthly savings we’re talking about! Hardly chump-change. 

Let’s take a closer look at PAPs. 

PAPs: What You Need to Know

PAPs are offered by pharmacy manufacturers to provide financial assistance to those taking a particular drug and who meet certain requirements. While each PAP is different, they generally provide assistance to those who meet one or a combination of the following criteria:

  • Have a high deductible health plan
  • Have an income of at or below a certain point
  • Do not have health coverage

Just as qualifications for each PAP are different, so are their means of providing assistance and reducing consumer costs. Some will cover your copay. When this happens, the pharmaceutical company still bills your employer (if they provide your insurance) the full amount—that’s just business.

“Our whole philosophy is that you, as a consumer, should understand the cost being borne by the system and be aware so you can try to minimize that cost. Why? Easy: it will pay dividends to you in the long run by keeping your premiums low,” Scott says. “If your employer’s premiums don’t go up, they don’t raise them for you, either.”

How Scott Saved Over $5,000 

In the short game, though, Scott knows that money talks. And $10 is a whole lot more digestible than the alternative—which is an example of what makes PAPs so attractive.

Here’s how Scott secured the reduced rate:

  • He searched for the phone number of the manufacturer and called to ask if they offered any type of assistance program. (Spoiler alert: they did.)
  • He talked with the representative to see if he met the program requirements due to his high-deductible health plan. (Spoiler again: he did.)
  • The representative said he’d notify Scott’s pharmacy of his discount, which was good for 24-months. (That’s all, folks. Discount received.)

It took all of twenty minutes—for the online search and the phone call combined—for Scott to save more than $5,000 for the year he was on the drug (that, due to the timing of his hospitalization, he would’ve paid 100 percent out-of-pocket). 

Today, it’s not even necessary to do your own online investigation. Instead, you can simply visit RXHope.com. This free, reference-based website lists over 330 drugs for which PAPs are available; it’s all right there for you.

Note that your drug may or may not be on the list—and if it is, you may or may not qualify for the PAP—but isn’t taking a few minutes to check worth the effort? 

Discount Cards: Save $5, $50, or More!

Sometimes, a PAP may not be available for a drug you’ve been prescribed. In that case—and, really, in any case—Scott says he recommends utilizing a prescription drug coupon card. 

He recalls having a prescription for Fluorouracil, a mild chemotherapy topical. He brought his coupon card (SingleCare, in this case) to the pharmacy, knowing what discount he was eligible for. The pharmacist (from a big chain store) said the cream would be $200, but—good news!—the store offered a $50 coupon. 

Scott knew that with his coupon—one the pharmacist said he may not be able to accept because he couldn’t file it electronically through the store’s system—could save him $100. Ultimately, Scott requested the paperwork to file on his own, saving himself the extra $50.

The pharmacist wasn’t trying to pull a fast one; he was simply dispensing drugs and offering discounts in the manner in which he was trained. In fact, Scott even had a brief chat with him—to the benefit of others within earshot who were obviously listening—about the way the card worked as well as other ways to save on prescriptions (like visiting RXHope).

Had Scott not had the discount card and the pharmacy not offered its coupon, he would have had to pay the full $200 for the cream—in essence, meaning there was $100 that nobody would have known about that the insurance company was keeping. This shows that insurance companies aren’t passing down all the rebates to pharmacists—all the more reason to be an engaged consumer of healthcare.

Scott had a similar situation in which his wife went in to pick up a prescription for Estradiol, a hormone replacement patch. The brand name was $140, and the generic was $80. With the drug discount card, they were able to drop that price to $45—a substantial savings on any long-term medication.

What’s Next?

At the end of the day, you want to save money on prescriptions, right? Rebates go on in the pharma world to employers and insurance carriers all the time. How do you get your own rebate? The true examples above are here to show you that it is possible to get in on that game.

As we’ve illustrated, with certain specialty or single-sourced drugs, manufactures will deal directly with you in the form of PAPs (if you meet their requirements). With other, more generic drugs, a discount card might be the way to go. 

The bottom line? There is no downside to looking at your savings options—a little time could go a long way to the bank.  

How much could you be saving? Once you get your prescription costs down, tell a friend. Help them. The more we speak up as consumers of healthcare, the more premiums will come down, and the more we can be a part of changing this industry.

How To Save $10,000+ On Your Healthcare Bills

The following is an excerpt from a conversation I had with Kirk Chisholm on The Money Tree Podcast

Are you happy paying thousands of dollars in healthcare costs you don’t use? Are you angry at the medical bills you incur for services that should cost a fraction of that amount? Are you looking for answers?

This week we interview a healthcare industry insider, Scott Heiser. He spills the secrets on what is actually causing the problems in our system. He also gives us some simple tips and tricks to save yourself thousands of dollars with only a few minutes of your time...

Listen to the entire episode to learn insider negotiation techniques on The Money Tree Podcast!

BEFORE YOU GO...GET OUR eBOOK FOR FREE!

Sign up below for our best insider techniques that will save you money on healthcare...
Learn from our members' success stories, like Kelly, who saved $1,600 on an MRI using these techniques
GET YOUR FREE COPY
>
close-link

GET MORE MONEY-SAVING TIPS, ALL IN ONE EBOOK

Sign up below for a FREE copy of our money-saving healthcare ebook.
Learn from our members' success stories, like Kelly, who saved $1,600 on an MRI using these techniques
GET YOUR FREE COPY
>
close-link