One of the health care overhaul’s most far-reaching provisions prohibits health plans from refusing to cover people who are sick or charging them higher premiums. Still, for people with serious medical conditions, the online health insurance marketplaces present new wrinkles that could have significant financial impact.
Obviously, premium costs will be an important consideration for consumers. But just as important will be a realistic assessment of what kinds of out-of-pocket costs they could expect with different types of policies and what subsidies they will be eligible for.
“Everybody should be factoring in cost sharing along with the premium to try to assess what their total financial exposure is,” says Jennifer Tolbert, director of state health reform at the Kaiser Family Foundadtion. (KHN is an editorially independent program of the foundation.)
The law requires new individual and small group plans sold on the online marketplaces, also called exchanges, and on the private market to cover a comprehensive set of 10 “essential health benefits,” including lab work and testing, prescription drugs, hospitalization and doctor visits. The benefits covered will be similar in all plans, but the proportion of the costs that a consumer pays will vary.
There will be four different levels of plan coverage, each identified by a precious metal: Platinum plans will pay 90 percent of covered expenses, on average; gold plans will pay 80 percent, silver plans 70 percent and bronze plans 60 percent.
Tax credits to help cover the cost of the premiums for plans sold on the exchanges will be available to people with incomes up to 400 percent of the federal poverty level ($45,960 for an individual in 2013), and cost-sharing subsidies will reduce the out-of-pocket costs for people with incomes up to 250 percent of poverty ($28,725 for an individual in 2013). The maximum amount that consumers will owe out of pocket for in-network medical claims will generally be capped at roughly $6,400 for individuals and $12,700 for families in 2014. (Those figures do not include money spent on premiums.)
How all those elements work together can have cost and coverage implications for people with high medical expenses. For example, even though the premium for a platinum plan will generally be higher than that of a bronze plan, the out-of-pocket spending cap may be significantly lower since platinum plans must cover 90 percent of expenses. For people who expect to hit their spending cap, buying a pricier platinum plan may actually result in lower total spending.
In addition to how much the plan costs overall, people with serious medical conditions need to carefully review whether the drugs they take are on the plan formulary, and the specialists and facilities they visit regularly are in the plan’s network, say experts, as well as their out-of-pocket costs to go out of the network.
Lab testing is the holly grail of any health plan, but is also the one that will most likely be the last to be looked at. Test results define 60-70% of the diagnosis and the course of treatment, but the cost of testing generally is within 3% of the total healthcare expense. Patients with medically necessary frequent testing may or may not be fully covered.
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