Beyond routine care and wellness, one of the major reasons for having health insurance is to protect yourself and your family in case of serious illness or injury. At Health Options, our medical management approach ensures that you also have a team of healthcare experts at your side in times of a serious medical crisis. In addition, our Care Managers are here for everyday wellness questions and at every step of recovery after a major medical incident.
Our Care Management Team partners with local agencies to find the help our Members need, from financial assistance to transportation, housing, and other issues affecting wellness and recovery. On-staff medical, pharmacy and healthcare experts help Members access medication and durable medical equipment, receive authorization support and assistance with provider outreach, and drug formulary education. The team also makes outbound calls to our Members to assist with chronic illness support or to provide post-discharge coordination from hospital stays. This collaborative approach to medical management focuses on improving care, creating positive health outcomes, and reducing the total cost of care.
What does a medical management approach look like to our Members? On a day-to-day basis, our in-house pharmacy team keeps Members updated about drug recall changes in medication availability and ways to access prescription medications at lower costs. Our team will also reach out to encourage immunizations, wellness visits, and other low-cost, or $0 cost-share benefits that can help our Members live their healthiest lives. In cases of hospitalizations and transitions to home, our medical management’s Site of Care Program offers Members the option to transition certain medications and infusions to a preferred site of care, including in-home care.
If a Member needs extra care for a particular condition, our team is instrumental in securing assistance. For example, one Member of our asthma outreach program had concerns about her condition combined with possible COVID-19 symptoms when the virus first emerged. Her COVID-19 symptoms kept her from seeing her primary care provider. After using a walk-in clinic for testing to determine she was COVID-19 negative, she continued to have a cough, low-grade fever, and fatigue. Our Care Management team was able to quickly find her an in-network pulmonologist who treated her with antibiotics for suspected pneumonia. She also had her asthma medications adjusted, and her condition improved.
Our hands-on strategies have resulted in more than $12.1+ million saved through Care Management programs since 2017, a 48 percent total reduction in our hospital readmission rate from 2018 to 2020. Our Script Saver program, led by in-house pharmacists, provided personal outreach to Members that led to out-of-pocket savings of $98,000 on medications in 2020. All of these efforts combined help improve health and reduce costs for our Members.
Call us if you have a question about prescription drug costs, need support for an upcoming medical procedure, or have a serious medical crisis. Our medical management team is in your corner, and they can be reached through Member Services at (855)624-6463, or use our secure email messaging.
Buying health insurance probably isn’t among the more exciting purchases you’ll ever make. But like it or not, it’s one of the most important each year. So, we want to help you get it right.
When you start shopping for health insurance, likely the first thing you’ll check is the price, or monthly premium. This makes sense, but just like buying a car or a house, price doesn’t tell the whole story.
You might think of the premium—the monthly charge for coverage—as a “sticker price.” But that’s only the beginning of what you’ll pay because most plans include co-pays, co-insurance and deductibles, which all add up to how much you pay out-of-pocket annually. You can learn more about those costs here.
It’s important to understand the benefits you’ll use because they directly impact how much you might pay to reach an annual maximum out-of-pocket limit, when insurance takes over and pays all your costs. Generally, the less you pay for insurance, the higher your deductible—and the more you’ll pay out-of-pocket as you use more services. So, knowing what you might need will help you limit out-of-pocket costs and maximize your benefits.
You’ll also want to understand types of coverage and be sure your carrier offers a comprehensive network. For example, an “HMO” which stands for health maintenance organization; gives you access to preferred providers; but you’ll need to stay in-network to get coverage. A second popular option, a “PPO,” or preferred provider organization, costs more but affords the freedom to use out-of-network providers at a slightly higher price.
Within each type of plan, deductible costs are designated by Bronze levels, which cost the least, and Silver, Gold and Platinum levels which cost more, but have lower deductibles. You can learn more about those levels here.
As you compare plans, you’ll get information about costs and coverages, but you’ll also see which plans offer services like wellness programs, dental or eye exams, or chronic care programs to support you along the way. Unique to Health Options, for example, is a care management program that partners with community services to support wellbeing, such as providing transportation to appointments or even meals for someone who is recovering at home.
You might consider a Silver, Gold or Platinum plan if:
You might consider a Bronze plan if:
While costs can weigh heavily when selecting a plan, it’s most important to choose coverage that fits your needs. And you might find help paying for insurance thanks to the recent passage of the 2022 Inflation Reduction Act, which extended Affordable Care Act premium tax credits. To find out if you’re eligible, visit CoverME.gov, Maine’s online Health Insurance Marketplace. For information or to get help choosing a plan, you can also call Member Services at (855) 624-6463.