Hidden Costs of “Affordable” Health Insurance Plans | Health insurance


The Affordable Care Act expanded access to health care by providing affordable coverage to millions of Americans. But finding a policy that meets your healthcare needs and budget requirements can be daunting.

For starters, the state health insurance markets and federal stock exchanges created by the Affordable Care Act provide consumers with a “one-stop shopping experience to easily compare the costs and benefits of plans,” says Kevin Lucia, principal researcher at Georgetown University. Center on Medicare Reforms. These marketplaces offer tax credits and subsidies to people with low and modest incomes.

To facilitate the shopping experience, insurers should provide a summary of benefits and coverage as well as a standardized glossary of medical terms. “When you compare plans, think about the health services you use or plan to use and the financial ramifications of not having access to the services and providers you want,” says Lucia.

Consider cost-sharing expenses

Many consumers focus on premiums, but out-of-pocket expenses (also known as “cost sharing”) can turn what at first glance seem like an affordable plan into a financial burden. Although cost-sharing fees vary from plan to plan, the Affordable Care Act caps out-of-pocket expenses at $ 6,850 for individuals and $ 13,700 for families in 2016.

Determining your potential out-of-pocket expenses can be tricky because “the language of cost-sharing – deductible, copayments, coinsurance – can be confusing,” says Susan Pisano, spokesperson for US health insurance plans, who represents the industry. health insurance. “But taking the time to calculate these costs is worth it.”

The deductible is the amount you must pay upfront for health services before your policy coverage takes effect. For example, a $ 1,000 deductible means you will need to spend $ 1,000 before the plan starts paying for covered services. Under the ACA, you are entitled to preventive care – such as annual checkups, vaccinations, mammograms, colonoscopies, and blood pressure tests – at no additional cost, whether or not you’ve reached the deductible..

Ellen Pryga, director of policy at the American Hospital Association, advises consumers to consider their money management style when deciding between a plan that has a low premium (but a high deductible) or a slightly premium. higher (but a lower deductible). “Some people have no difficulty setting up a savings account to cover the deductible,” she says. “For others, saving is more difficult. It might be better if they pay the slightly higher premium so that they are not tempted to touch that savings account for other reasons.”

Co-payment is the lump sum ($ 20, for example) that you pay each time you access care, such as a visit to the doctor. “These little things can add up depending on how you use the services,” says Pisano. For example, user fees can multiply quickly if you take multiple medications prescribed by various specialists, all of which require a visit to the doctor to renew a prescription.

Coinsurance refers to the percentage of the cost of a covered health service that you have to pay. Let’s say your plan has 20% coinsurance. An office visit that costs $ 100 leaves you with a 20 percent coinsurance payment of $ 20. These costs can add up quickly too, when you consider that 20% of an emergency department visit or long hospital stay can result in thousands of dollars in coinsurance payments. For example, the average cost of an uncomplicated pregnancy and newborn care can total over $ 30,000.

Look beyond the cost of premiums

Avoid the temptation to automatically select the policy with the lowest premium, as you may be paying more for your long-term health care. Premiums refer to the annual cost of an insurance plan (usually paid in monthly installments), whether or not you have access to health care services. Plans with low premiums typically have high out-of-pocket expenses to cover deductibles, copayments, and coinsurance, so you might be struggling with bills you didn’t expect.

People under the age of 30 and some people with limited incomes may purchase catastrophic health plans that cover worst case scenarios. While these plans typically have lower premiums than full plans, they come with high deductibles and out-of-pocket fees, so you’ll need to be prepared to manage these expenses. These plans will cover certain preventive measures at no cost to consumers.

Get the coverage you need

Make sure the plan covers the medical care you need, especially if you have a chronic condition (such as diabetes, asthma, multiple sclerosis, and arthritis) that requires ongoing care. “If you buy coverage just because it’s cheap and doesn’t provide the services you need, then you’ve wasted your premiums,” says Pryga.

The same goes for prescription drugs. Insurers must cover at least one drug in each category and class of drugs. But your particular drug might not be on the list, which will leave you with higher out-of-pocket expenses. “Look at the cost of your medications in different plans to see which ones are reimbursed at a higher rate,” says Cheryl Fish-Parcham, deputy director of health policy at the nonprofit Families USA.

Take a close look at the supplier network

Find out if the plan’s network of doctors and hospitals includes your primary care doctors and specialists, or you could end up stuck with the bill. Getting out of your plan’s provider network can come with a hidden cost known as “balanced billing,” says Lucia. “Off-grid providers will charge fees that exceed the amount your plan reimburses for a covered service. Some plans also require a referral to see a specialist and authorization from the insurer before undergoing an expensive procedure.

The ACA sets a minimum standard of care, known as essential health benefits, for 10 categories. But insurers have flexibility as to the type and number of services offered in each category. For example, insurers must cover mental health services, but plans will vary depending on the number of therapeutic visits allowed per year. “There are going to be loads of exclusions in the policies, even with the essential health benefits,” Pryga said.

If you still feel overwhelmed with purchasing health insurance, rest assured. Help is available online at HealthCare.gov (or CuidadoDeSalud.gov for Spanish-speaking consumers), by phone at 800-318-2596 24 hours a day, and in person.

“The Affordable Care Act sets up a system of ‘browsers’ that will be available on an individual basis to educate consumers about their health insurance options and guide them through the enrollment process,” says Vicki Breitbart, director of the Health Advocacy Program at Sarah Lawrence College. “You don’t have to venture into the quagmire alone.”


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