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Navigating Private Insurance in Canada

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Canadians are often uncertain about the role and limits of their private insurance coverage. Let’s change that.

For this webinar, we were joined by Suzanne Lepage, private health plan specialist, for a discussion of Canada’s private drug plan marketplace and its overlap with government provided services. She walked us through what to expect in terms of coverage and answer audience questions about private insurance. She broke down the Canadian health care system, helped us understand how insurance and employers interact, and gave us tips for contacting our insurance representatives for more information or to appeal the denial of a claim.

She also gave us a tour of the coming changes to Ontario's private insurance marketplace with the introduction of OHIP+.

Published in: Healthcare
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Navigating Private Insurance in Canada

  1. 1. REPRODUCTION REQUIRES PERMISSION OF SUZANNE LEPAGE CONSULTING INC. 1 “Navigating Private Insurance in Canada” Webinar November 30, 2017 Canadian Cancer Survivor Network (CCSN) Presented by: Suzanne Lepage, Private Health Plan Strategist
  2. 2. REPRODUCTION REQUIRES PERMISSION OF SUZANNE LEPAGE CONSULTING INC. 2 Overview 1. Unique Characteristics of Private Payers 2. Private Payer Stakeholders 3. Private Payer Coverage 4. Private Drug Plan Cost Pressures 5. Private Payer Trends 6. Declines and Appeals 7. Patient’s Guide to inquiring about Private Drug Coverage 8. OHIP+ and Private Plans 9. Questions and Discussion
  3. 3. REPRODUCTION REQUIRES PERMISSION OF SUZANNE LEPAGE CONSULTING INC. Canadian Drug Expenditures Public Private Split 3 63.6% 36.4% Private Public CIHI 2017 62.0% 38.0% Insurer Out of Pocket
  4. 4. REPRODUCTION REQUIRES PERMISSION OF SUZANNE LEPAGE CONSULTING INC. Private Payer Share Much Larger in Canada Retail spending on pharmaceuticals by type of financing, 2015 or nearest year
  5. 5. REPRODUCTION REQUIRES PERMISSION OF SUZANNE LEPAGE CONSULTING INC. 5 Canadian Health Insurance Facts CLHIA - Canadian Life and Health Insurance Facts - 2017
  6. 6. REPRODUCTION REQUIRES PERMISSION OF SUZANNE LEPAGE CONSULTING INC. 6 Unique Characteristics of Private Payers
  7. 7. REPRODUCTION REQUIRES PERMISSION OF SUZANNE LEPAGE CONSULTING INC. 7 Private payers are different • Employers view drug coverage as part of compensation package, not for health. • Managed by Human Resources – not health care providers • Stakeholders are suppliers and competitors • Insurers target “customer” = plan sponsors (employers) • Confidential “Business to Business” transactions • Insurer’s priority relationships with their customers -plan advisors and plan sponsors • Lack of transparency • No obligation that plans, coverage decisions shared publicly
  8. 8. REPRODUCTION REQUIRES PERMISSION OF SUZANNE LEPAGE CONSULTING INC. 8 Private payers are different • Concern about competitors gaining market intelligence • Confidential communication targeted at their customers: Plan Advisors and Plan Sponsors • Plan Members can access their own coverage information via insurer call centre or secure web portal
  9. 9. REPRODUCTION REQUIRES PERMISSION OF SUZANNE LEPAGE CONSULTING INC. 9 1. Premiums based on the makeup of their group and claims experience from previous years 2. Pool charges for extra risk protection for claim costs that go over a threshold e.g. $10,000 per year Employers pay for health benefits
  10. 10. REPRODUCTION REQUIRES PERMISSION OF SUZANNE LEPAGE CONSULTING INC. Private Payer Stakeholders 10
  11. 11. REPRODUCTION REQUIRES PERMISSION OF SUZANNE LEPAGE CONSULTING INC. 11 Plan Members ~ 19M Plan Sponsors ~400-600K Plan Advisors ~3,000 Insurers ~15 Pharmacies ~9,000 PBM ~3 Unions
  12. 12. REPRODUCTION REQUIRES PERMISSION OF SUZANNE LEPAGE CONSULTING INC. Private Payer Coverage 12
  13. 13. REPRODUCTION REQUIRES PERMISSION OF SUZANNE LEPAGE CONSULTING INC.
  14. 14. REPRODUCTION REQUIRES PERMISSION OF SUZANNE LEPAGE CONSULTING INC. All private plans are different • Some private plans may cover a drug and some may not • Coverage can vary • within one insurer • even within one employer • Individual employers choose coverage for their employees • They decide what they want to cover and how much coverage (except QC) • Their premiums are based on the plan design and actual claims • Each insurer offers a wide variety of plans to meet different needs • Some plans may cover your drug and others may not • Different prices for different plans 14
  15. 15. REPRODUCTION REQUIRES PERMISSION OF SUZANNE LEPAGE CONSULTING INC. All private plans are different • Access is more than – “is the drug covered?” • There can be other features that will impact an individual patient access via their private drug plan For example: 1. Prior authorization 2. Plan maximums 3. Step Therapy 15
  16. 16. REPRODUCTION REQUIRES PERMISSION OF SUZANNE LEPAGE CONSULTING INC. 16 Prescribed Prescription /Open Provincial Managed Formulary Frozen /Custom Formulary Formulary Co-pay Multi tiered plans Sliding Coinsurance DeductibleFlat co-pay% Coinsurance Limits Quantity Limits Days Supply Trial Script Ther. Class Limits Ther. Class Incl/excl. Pricing and Maximums Disp Fee Caps Lifetime Maximum Annual Maximum Generic Pricing Allowable Price Plan Sponsor Plan Design Decisions
  17. 17. REPRODUCTION REQUIRES PERMISSION OF SUZANNE LEPAGE CONSULTING INC. 17 Private Drug Plan Cost Pressures
  18. 18. REPRODUCTION REQUIRES PERMISSION OF SUZANNE LEPAGE CONSULTING INC. Private Drug Plan Claim Costs • Average eligible amount per cardholder $445 • Up 5.8% from 2015 • Specialty drugs (>$10,000)  25.9% of total claims costs  0.96% of number of claims • Average annual amount per claimant  $18,549 for specialty drugs  $509 for non-specialty Source: TELUS Health 2016 Drug Trend Report
  19. 19. REPRODUCTION REQUIRES PERMISSION OF SUZANNE LEPAGE CONSULTING INC. Private Drug Plan Premiums • 65% of employers experienced cost increases in their benefit plan1 • 66% report total benefit costs have increased over the past 3 years3 • 80% are concerned that growing costs will exceed the rate of inflation over the next 3-5 years3 1. TELUS Health. http://www.bppgcreative.ca/pdfs/b/bc-medication-management-drug-benefit-plan-cost.pdf. 2. Sanofi Canada Healthcare Survey 2015. http://www.sanofi.ca/l/ca/en/layout.jsp?scat=C3588838-0978-4F25-9A92-6F37FA912C05. 3. Sanofi Canada Healthcare Survey 2016. http://www.sanofi.ca/l/ca/en/layout.jsp?cnt=65B67ABD-BEF6-487B-8FC1-5D06FF8568ED.
  20. 20. REPRODUCTION REQUIRES PERMISSION OF SUZANNE LEPAGE CONSULTING INC. Private Payer Trends
  21. 21. REPRODUCTION REQUIRES PERMISSION OF SUZANNE LEPAGE CONSULTING INC. Private Payer Trends 1. Increased scrutiny of pipeline and new drug submissions 2. Case management of drug claims 3. Preferred provider pharmacy networks (PPN) 4. Increased focus on Prior Authorization 5. Integration – provincial drug plans and Patient Support Programs 6. MAC – Maximum Allowable Cost 7. Step Therapy 8. Growth of managed formularies 9. Delayed Listings 10. Plan Maximums (annual or lifetime) 11. Product Listing Agreements
  22. 22. REPRODUCTION REQUIRES PERMISSION OF SUZANNE LEPAGE CONSULTING INC. Declines and Appeals
  23. 23. REPRODUCTION REQUIRES PERMISSION OF SUZANNE LEPAGE CONSULTING INC. 23 “My drug is not covered!!!” Strategies are situational Do you know why drug is not covered?
  24. 24. REPRODUCTION REQUIRES PERMISSION OF SUZANNE LEPAGE CONSULTING INC. 24 Possible reasons a drug may not be covered by a private plan Reason Potential Strategy 1 New drug still under review DIN not listed on payers system Ask when review will be completed and decision(s) will be made 2 Drug plan mimics the provincial formulary Provincial formulary doesn’t cover the drug Listing on provincial formulary
  25. 25. REPRODUCTION REQUIRES PERMISSION OF SUZANNE LEPAGE CONSULTING INC. 25 Possible reasons a drug may not be covered by a private plan Reason Potential Strategy 3 Drug is part of a class that is excluded/limited on drug plan Employer would have to change drug plan 4 Drug plan is managed formulary Formulary manager has reviewed the new drug and decided not to cover Ask formulary manager why they decided not to cover drug. Clinical or cost effectiveness? Develop strategy to appeal decision
  26. 26. REPRODUCTION REQUIRES PERMISSION OF SUZANNE LEPAGE CONSULTING INC. 26 Possible reasons a drug may not be covered by a private plan Reason Potential Strategy 5 Drug Plan has specific criteria that must be met for patient to be covered for drug (diagnosis, prior treatment, step therapy, infusion location) Patient does not meet criteria Ask formulary manager why they decided on specific criteria for this drug If criteria does not align with approved indications or guidelines, develop strategy to appeal decision 6 Drug plan requires that the patient try to access alternate coverage first e.g. special government program Apply for alternate coverage Ask if there is an opportunity for interim coverage by the private plan while they wait for the alternate program to review patient application
  27. 27. REPRODUCTION REQUIRES PERMISSION OF SUZANNE LEPAGE CONSULTING INC. 27 Possible reasons a drug may not be covered by a private plan Reason Potential Strategy 7 Drug is covered, but patient has reached their individual maximum on their plan Employer would have to change drug plan or allow patient exception Explore other potential coverage (e.g., catastrophic drug coverage in your province)
  28. 28. REPRODUCTION REQUIRES PERMISSION OF SUZANNE LEPAGE CONSULTING INC. Types of Appeals Medical • Situational - based on specific reason for patient decline • Need to know why coverage was declined • Patient doesn’t meet criteria? • Payer doesn’t cover drug? • Physician appeals to insurer • Makes case for medical necessity • Explains why alternate (covered) treatments aren’t sufficient for this specific patient 28
  29. 29. REPRODUCTION REQUIRES PERMISSION OF SUZANNE LEPAGE CONSULTING INC. Types of Appeals Employer • Situational - based on specific reason for patient decline • Need to know why coverage was declined • Specific plan chosen by employer does not cover this drug? • Provincial mimic or managed formulary? • Employer is ultimate payer who chooses coverage and has the ability to change it or make an exception • Employee appeals to their employer • Requires disclosure of condition • Develop “business case” of why employer should cover drug 29
  30. 30. REPRODUCTION REQUIRES PERMISSION OF SUZANNE LEPAGE CONSULTING INC. 30 Patient’s Guide to inquiring about Private Drug Coverage
  31. 31. REPRODUCTION REQUIRES PERMISSION OF SUZANNE LEPAGE CONSULTING INC. 31 1. Ensure you have employee (and spouse if applicable) drug plan: • Contract or policy number • Personal certificate or identification number 2. Get a copy of the benefits booklet that outlines the employer benefit plan 3. Get the phone number for the insurance company 4. When calling the insurance company they will ask which drug the inquiry is about: • Drug name • DIN (Drug Identification Number)
  32. 32. REPRODUCTION REQUIRES PERMISSION OF SUZANNE LEPAGE CONSULTING INC. 32 5. If you are told the drug is “Not Covered” get more information on why the drug is not covered • “Can you please explain why this drug is not covered by the plan? • I am not familiar with insurance coverage. Could you help me understand why this plan does not cover this drug? I have the benefits booklet right here. Can you explain to me the specific terms that explain why this drug is not covered?” • “If you are unable to help me, can I please speak to someone who can? Can you transfer me to your supervisor?” • If you are referred back to your employer: • “Thank you, but for privacy reasons, I would rather not discuss my (or my family member’s) medical condition and medication needed with my employer. Can you please explain to me why this drug is not covered?
  33. 33. REPRODUCTION REQUIRES PERMISSION OF SUZANNE LEPAGE CONSULTING INC. OHIP+ and Private Plans 33
  34. 34. REPRODUCTION REQUIRES PERMISSION OF SUZANNE LEPAGE CONSULTING INC. • 2017 Ontario budget • New drug program effective January 1, 2018 • Offers free medication to Ontarians < 25 yrs who are covered by OHIP • Coverage will be provided regardless of family income or private insurance benefits and enrollment in OHIP+ will be automatic. • Ontario is investing $465 million to provide youth with access to 4,400 Ontario Drug Benefit (ODB) OHIP+ and Private Plans
  35. 35. REPRODUCTION REQUIRES PERMISSION OF SUZANNE LEPAGE CONSULTING INC. • Employers increasingly concerned about growing drug plan costs • OHIP+ seen as a way to relieve cost pressures by transferring expenses and risk to ODB • In order to maximize potential savings • Will make changes to their coverage for this age group • Will have downstream impacts on patient access to medication OHIP+ and Private Plans
  36. 36. REPRODUCTION REQUIRES PERMISSION OF SUZANNE LEPAGE CONSULTING INC. Maximize provincial coverage and transfer the claims risk to the ODB 1. Eliminate all drug coverage for plan members < 25 yrs 2. Eliminate coverage for ODB drugs for plan members < 25 yrs 3. Require plan members < 25yrs to apply for EAP coverage before approving private coverage How private coverage could change
  37. 37. REPRODUCTION REQUIRES PERMISSION OF SUZANNE LEPAGE CONSULTING INC. Private Plans - Transition strategy – EAP Drugs January 1 – June 30, 2018 Insurance carriers will continue to cover the following drugs without requiring an EAP rejection: 1. Antibiotics and anti-infectives (including antiviral and antifungal agents) 2. Blood thinners (low molecular weight heparins) 3. Drugs with low EAP approval rates
  38. 38. REPRODUCTION REQUIRES PERMISSION OF SUZANNE LEPAGE CONSULTING INC. • All other EAP drugs will be handled on a insurer by insurer basis • May require EAP rejection in order to approve private coverage a. as of January 1, 2018 b. or allow a grace period • Insurance carriers still developing their communication plans • Many will develop custom communication to plan member/patient who are taking an EAP drug which will provide specific direction Private Plans - Transition strategy – EAP Drugs
  39. 39. REPRODUCTION REQUIRES PERMISSION OF SUZANNE LEPAGE CONSULTING INC. 39 Summary 1. Unique Characteristics of Private Payers 2. Private Payer Stakeholders 3. Private Payer Coverage 4. Private Drug Plan Cost Pressures 5. Private Payer Trends 6. Declines and Appeals 7. Patient’s Guide to inquiring about Private Drug Coverage 8. OHIP+ and Private Plans 9. Questions and Discussion
  40. 40. REPRODUCTION REQUIRES PERMISSION OF SUZANNE LEPAGE CONSULTING INC. 40 Questions and Discussion Suzanne Lepage (519)954-8873 (Business) (519)635-5175 (Cell) suzanne@suzannelepage.ca www.suzannelepage.ca ca.linkedin.com/in/suzannelepage/ @suzannelepage
  41. 41. REPRODUCTION REQUIRES PERMISSION OF SUZANNE LEPAGE CONSULTING INC. Canadian Cancer Survivor Network Contact Info Canadian Cancer Survivor Network 1750 Courtwood Crescent, Suite 210 Ottawa, ON K2C 2B5 Telephone / Téléphone : 613-898-1871 E-mail jmanthorne@survivornet.ca or mforrest@survivornet.ca Web site www.survivornet.ca Instagram: @survivornet_ca Twitter: @survivornetca Facebook: www.facebook.com/CanadianSurvivorNet Pinterest: http://pinterest.com/survivornetwork/

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