Consumers must be savvy to benefit from health reform

By Erica Cohen

Never before had I been so excited for my health insurance to change. While I typically dread the hassle of dealing with a new policy with different in-network providers, this time I expected my coverage to improve. Thanks to the Affordable Care Act (ACA), the new plan would cover all government-approved preventive care without co-pays. This, I thought, would save me money.

I called my pharmacy benefits manager and said, "Sign me up!" The company is one of the largest pharmacy benefit management companies in the United States, so I expected its employees to know the relevant provisions of the ACA well.

After taking all of my information, a customer service representative informed me of the amount of the co-pay that would apply. "Impossible," I replied, "ACA covers this as a preventive service." It turned out that the representative was right, but it took me a lot of time and effort to get an accurate explanation of why.

The representative's first explanation was, "Well I don't think the preventive care section of ACA is in effect yet." I informed her that it has, in fact, been in effect since August 1, 2012.  After a few minutes, I was presented with an alternate excuse: this particular service is not covered.

Unfortunately, she was dealing with a customer who has read up on ACA. I replied, "Yes it is. ACA applies to all approved preventive services." She then suggested that it was not covered because it involved a drug that was not on my insurer's formulary, which is a list of preferred medications.

The customer service representative decided to talk to a pharmacist, although it wasn't clear why a pharmacist would have a better understanding of ACA than she. After a 10-minute wait – and a total of 65 minutes on the phone – she told me she had no answer and I would need to contact my insurer.

So, after taking a few deep breaths, I called my insurer and was informed that my plan was "grandfathered" and would not cover preventive health services until January 1, 2013. Grandfathered insurance plans are exempt from certain provisions of ACA. The insurance company representative assured me that this service would be covered with no co-pay beginning January 1. Why did it take so long to get the right answer?

It is difficult to understand how the average consumer can take advantage of ACA benefits if representatives of insurers and pharmacy benefit managers are unable to provide reliable information on how these provisions work. I consider myself fairly savvy on this topic. But what about other people? I have to imagine that most would have given up when the customer service representative gave the first excuse.

While the final explanation for my co-pay turned out to be correct, the first three were not. It should not take an hour and a half to find out why ACA's preventive care provision does not apply to my plan.

Consumers must be aware of their rights and their insurance companies' obligations. It is clear that we will need to advocate for ourselves rather than relying on the knowledge of the people who should (but often don't) know the law.