Navigating Healthcare in 2023

When it comes to healthcare, hospitals, and health insurance for 2023, the old buyers’ adage should apply, except in this case it would read, “Patients Beware.” Health insurance costs continue to rise with $5,000-plus deductibles per person and $2,000 premiums each month for many families. Add in healthcare costs for co-payments, medicine, supplies, procedures and co-insurance, and the expenses become even more costly.

Health insurance companies point to the increased cost as a result of the surge in hospitals buying up medical practices throughout Atlanta. According to AHIP, a national advocacy group for health insurance providers and formerly known as America’s Health Insurance Plans, “As hospitals gain more market power by snapping up doctor practices, they can control referrals and demand higher prices, which, in turn, makes premiums and costs for everyone higher.”

Independent medical practices and freestanding medical facilities, which typically offer much lower pricing, find it harder to compete with the large hospitals and healthcare systems. Some physicians report taking early retirement or selling their practices to the large healthcare systems as a result.

Hospital executives blame the increased patient costs on higher deductibles for patients imposed by insurance companies, as well as the increased profits they believe health insurance companies are making. Caught in the middle are patients trying to find quality healthcare at an affordable price.

Case in point: Northside Hospital charged $8,240 for a Prolia injection to treat a patient’s osteoporosis. The United Healthcare negotiated rate allowed $3,951 to be charged. A year earlier, the charge from Paragon Infusion Center, an independent facility, was $4,573.40, or almost half the price for the same injection. That year, the Blue Cross and Blue Shield of Georgia negotiated rate was $1,357.04. From one year to the next, the cost to the patient increased by almost $2,600 because of different insurance policies and moving from an independent infusion center to the outpatient area at a hospital. Paragon was not in the United network of providers, and the physician directed the patient to Northside Hospital, which had purchased her practice a few years earlier.

When asked about the price discrepancy, Lee Echols, senior vice president of marketing and communications at Northside said, “Today’s healthcare environment is complicated, but Northside and many other healthcare systems have several tools in place to help patients navigate both care and the cost of care.”

Julie Joffre Benveniste, owner of The Benveniste Insurance Group

While not specifically addressing the cost involved with the hospital, Echols recommended contacting a hospital’s billing customer service team to request costs before scheduling hospital procedures. He also recommended visiting www.northside.com/patients-visitors/billing-and-insurance/price-estimates to find estimated costs or www.northside.com/patients-visitors/billing-and-insurance for more billing information. In the case of the Prolia injection, the team scheduling the injection was unable to provide the anticipated cost in advance and did not refer the patient to the billing department, though they did indicate that her insurance had approved the injection.

The Affordable Care Act (ACA) Marketplace for health insurance opened earlier this month on Nov. 1, and healthcare experts stress that education is a must as consumers make decisions about their insurance coverage and healthcare for 2023. Whether working with an independent insurance broker or on their own by visiting www.healthcare.gov, buyers will find more plan options this year than in the past.

What many consumers do not know is that they may qualify for a government tax credit or subsidy, thanks to the American Rescue Plan Act, passed in March 2021. This bill expanded funding so that more consumers will qualify for the credit and lower monthly premiums. In addition, more people have been able to secure a cost sharing reduction (CSR), which lowers the amount paid for deductibles, co-payments, and co-insurance. To be considered for a CSR, individuals and families must enroll in a silver tier health plan. While the monthly premiums are typically more expensive, the overall savings at the end of the year can be considerable.

Tom Boyd, an independent insurance broker with Bogrow Insurance Group, has directed many of his clients to silver plans so they may take advantage of the tax credit and CSR benefits.

Julie Joffre Benveniste, owner of The Benveniste Insurance Group, indicated that some buyers may wish to consider higher premium policies with lower deductibles if they have any ongoing health conditions. She recommended looking at all costs associated with the health plans, not just the cost of the monthly premiums.

“The cost of visits to the PCP (primary care physician) and specialists, medicine and in-patient hospital coverage are among the factors that should impact a consumer’s selection when reviewing plans,” she emphasized.

To review a variety of policies and to see if one qualifies for a tax credit, she pointed to www.healthsherpa.com.

Tom Boyd, independent insurance broker with Bogrow Insurance Agency

“Many people do not realize they may qualify for a tax credit, often saving them hundreds of dollars or more. For example, a family of four with an income of $150,000 qualified for a tax credit of more than $300 each month when they applied for health insurance in 2022,” Joffre Benveniste added.

Boyd also mentioned the savings offered as a result of the American Rescue Plan Act and shared an example of a couple who had a combined joint income of $260,000 and qualified for a federal tax subsidy. He credited the relief bill with making insurance affordable for many more consumers and for the entry of several additional insurance companies back into the Georgia market.

Both Bogrow and Joffre Benveniste see health insurance as asset protection. “Just like car insurance, health insurance is for that G-d forbid moment when you want to be covered,” said Joffre Benveniste. To that end, indemnity plans sold by companies such as Manhattan Life can supplement a health insurance policy by providing actual funds to individuals when they are hospitalized, require outpatient services, or receive cancer care. Indemnity plans are not available on the government exchange but may be purchased through independent agents.

An alternative to purchasing a traditional health insurance plan is participating in a healthcare sharing ministry. While similar to a traditional plan, there are distinctions. Healthcare costs are shared among members with common ethical or religious beliefs. United Refuah HealthShare is a Jewish network, though many other health sharing ministries are not restrictive and simply require belief in a higher power.

Monthly premiums, called “monthly share amounts” in industry parlance, tend to be less expensive and claims or “share requests” are handled by patients submitting bills to the ministry directly unless physician offices agree to manage administrative process.

Insurance experts recommend several steps to ensure individuals select the best plans for their needs. First, consumers should contact their current physicians and hospitals to be certain they are on the plans considered. They should keep in mind that the insurance directories listing physicians are not always current. In addition, buyers need to check that prescriptions are on the health plan’s formulary or ask if there are alternative choices. Otherwise, they may pay the full price of the prescriptions.

Consumers may buy individual and family plans through Jan. 15, 2023, on the ACA marketplace and through insurance brokers. For a Jan. 1, 2023, start date, policies must be purchased by Dec. 15, 2022. Otherwise, a person’s existing 2022 policy will roll over into 2023. Policies bought between Dec. 15, 2022, and Jan. 15, 2023, will start on Feb. 1, 2023.

Healthcare industry insiders acknowledge seeking care and coverage has become more complex, difficult to navigate and expensive. Conducting independent research, contacting an insurance broker for guidance, and speaking with administrators at physician offices may be the best path to help ensure buyers find the most appropriate healthcare coverage for 2023.

Julie Joffre Benveniste may be reached at julieb@gahealthbrokers.com or (404) 316-7514. Tom Boyd may be reached at (678) 404-BOYD (2693).

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