Navigating the world of health insurance

Joseph Ruffolo

December can be a difficult month for folks looking to make health care decisions for the coming new year.

That even applies to Niagara Falls Memorial Medical Center President and CEO Joseph Ruffolo.

“Sometimes I hate seeing the mailman coming (in October),” he says with a laugh, describing the almost daily delivery of letters, pamphlets, booklets and other offerings from health insurers pitching their latest supplemental Medicare offerings. “It’s just crazy, it’s overwhelming the different plans, and what they offers, that seniors have to sort through.”

Even his own parents would turn to him to guide them through the health care selection process.

“They think I’m the health care expert,” Ruffolo said. “And they’re going through the plans and one is good for when they’re (in Niagara Falls), but it doesn’t work when they’re in Florida and they’re asking me what they should do.”

The Ruffolos are not alone when it comes to figuring out how to get affordable and appropriate health care. As the end of the year approaches, people from their teens to mid-20s to their 60s, 70s and 80s, are struggling to decide how to protect themselves and their families.

INSURANCE ISN’T ENOUGH

When it comes to health care, having insurance either public or private isn’t always enough for consumers.

“Having insurance doesn’t necessarily guarantee you access to health care,” Ruffolo said. “it just means you’re insured.” Memorial’s CEO says if your deductibles or co-pays are too high, you may choose not to use your insurance even if you need treatment.

“I may need a gallbladder (removed),” Ruffolo said. “But if the deductible is $5,000 and that means I won’t be able to put food on my table to meet it, I may choose not to have (surgery).”

That’s why he’s critical of many of the exchanges set up under the Affordable Care Act. Ruffolo maintains that even though more people are insured today than before the ACA, it doesn’t necessarily mean they have health care.

“The lowest premiums on the exchanges have very high deductibles,” he said. “If you can’t make the deductibles, the exchanges by themselves ins’t a solution.”

Ruffolo is also critical of insurance carriers who enter new markets offering low-cost “teaser” premiums, only to “jack it up” the following year.

TURN TO THE NAVIGATORS

Memorial Medical Center offers what are known as navigators to help folks who live in the Niagara Region to make smart choices when they look to access insurance through the health care exchanges. They work with people whose are too young for Medicare, have too much income for Medicaid and don’t have employee-sponsored health insurance to make the best possible choices base on premiums and what the plan providers.

With an expanding array of offerings from private insurers in the Medicare realm, Ruffolo thinks the federal government ought to look at making navigators available to seniors as well.

“The federal government saves money by having insurers provide their Medicare policies,” he said.

“So the federal government should provide block grants to the states to provide navigators guide seniors in choosing Medicare plans. For someone who had never had to buy insurance all their life and now has to buy insurance, that’s a huge burden.”

Jeff Baxter, the director of Memorial's navigator program says folks in need of guidance need only go https://nystateof health.ny.gov/ and click on the Enrollment Help button to get connected with a navigator.

"The navigator program is design to help people," Baxter said. "We can walk you through the website."

THE MEDICAID DILEMMA

Ruffolo seems less than certain about how to solve the growing disincentive for work that he sees in the current Medicaid program and the impact of taking scores of potential premium payers, who could help hold costs down, out of the health care system.

“Medicaid pays everything,” he said. “There are no co-pays.”

But as wages begin to rise and the working poor begin to move up in the workforce, they face a daunting choice. Keep working and earning and lose access to Medicaid or leave the workforce and retain those benefits.”

“You’re working, but you’re still poor and (with employer-sponsored health care) you have deductibles and co-pays,” Ruffolo said. “So why would you choose that over Medicaid?” 

HOW TO MAKE YOUR HEALTH CARE WORK

So how can a consumer navigate the wild west that is American healthcare and make the smartest choices for themselves and their families?

Ruffolo says you should find the answers to five fundamental questions to make your choices.

First, he say, make sure you know your deductibles and co-pays compared to the premium you be paying. Be prepared for those costs.

Second, who are your medical providers and are they a part of the insurance plan’s network. Out-of-network costs can be substantial.

Third, make sure the insurance plan does not contain any care-outs for pre-existing conditions. Fourth, if you need pre-authorizations for consulting specialists or for medical procedures, make sure the plan requires timely action on those pre-authorizations.

Fifth, look for plans with zero co-pays for annual wellness visits and for preventive testing like mammograms.

Make sure if you use specialty drugs that your drugs are covered by the plan’s prescription benefit and that chronic illnesses don’t incur additional costs.

Finally, Ruffolo added, “Make sure you can come to Memorial for care.”

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