"If you like your health care plan, you can keep it," has been uttered as many times in the past few months as it has in the past few years. President Obama’s bold and reassuring statement proved to be untrue with as many as 4 million people nationwide losing plans that do not comply with the Affordable Care Act’s requirements.While journalists, pundits and politicians continue to quibble over the actual number of people losing their policies, it is abundantly clear that the new ACA policies look markedly different, not only from the old policies, but from many of the existing group polices. In fact a recent Associated Press-GfK poll reported that 59% of respondents receiving job-based or private insurance reported deductibles and co-payments are increasing in 2014. 69% reported higher premiums.
As a federally funded, state certified Navigator organization, it is our job to enroll at least 3,000 individuals in Marketplace insurance plans before September 1, 2014. The first 60 days of the enrollment period were marred by a website plagued by glitches and shutdowns. Hundreds of hours were spent in futile attempts to get consumers into the system, and even more hours spent attempting to view the 132 plans offered in Palm Beach County.
December 1st marked a significant improvement in the website’s operation. Although there are still significant glitches and issues remaining, and the process is far from smooth, we are now consistently enrolling consumers. In fact, as of the middle of December, Florida is leading the enrollment efforts in the federal Marketplace.
Consumers have now begun the arduous task of examining the 132 plans. Our task is assisting consumers with finding the “right” plan – one that is affordable and that will meet their needs when used. Beyond the sometimes limited provider networks, cost becomes a significant factor.
Marketplace plans are divided into “metal levels”: Bronze, Silver, Gold and Platinum, based on the sharing of health care costs between the insurance company and the patient. Bronze plans are the least expensive plans, with the patient absorbing 40% of the costs of care, and Platinum plans are the most expensive with the patient absorbing only 10%. Unfortunately, this is of marginal help in determining the cost of use.
Of the plans offered in Palm Beach County 63 are HMOs, (Health Maintenance Organizations) 52 are EPOs (Exclusive Provider Organizations) and 17 are PPOs (Preferred Provider Organizations). Of the PPOs, 6 are Bronze Level, 6 are Silver Level and 4 are Gold Level Plans. Forbes Magazine categorized this trend as a “throwback to the old HMO model of the 1990s”. (Forbes, Gottlieb, S. 12/9/2013) Many of our consumers come in having negative views of HMOs, often requesting only PPOs.
But in the Marketplace, the PPO is no longer the premier plan, and there is not even a Platinum Level PPO plan offered. In fact, of the 15 premium Platinum Plans, 5 are HMOs and 10 are EPOs. And while the HMOs adhere to the traditional model and do not provide for out-of-network coverage, many of the EPOs break with tradition and offer out-of-network benefits, although generally with a 50% coinsurance after the deductible is met. In addition, many of the EPOs have high deductibles (over $6,000 for Bronze plans) which must be met before any benefits are paid.
While affordability is a subjective term, many of the plans are reasonably priced, particularly when premium tax credits are taken into account. Sicker, older individuals reap the greatest benefit, being able to purchase a $0 deductible, $2,000 maximum-out-of-pocked EPO for around $750 a month, less than half the cost of such coverage prior to the Marketplace. After addressing affordability of the premiums, we have to evaluate whether a consumer can afford to use the plan.
One aspect is sure to create the most challenges for both patients and healthcare providers – the almost uniformly high deductibles. The ACA placed a maximum annual cap on deductibles and out-of-pocket costs: $6,350 for the deductible and $6,350 for the maximum out-of-pocket costs. The amounts are almost double for families. Many plans have taken advantage of this provision with 71 of the 132 plans having an annual deductibles between $3,000 and $6,350.
There is also a seemingly endless array of what the plans pay before and after meeting the deductible. One plan, for example, will have a $50 co-pay before meeting the deductible and a 20% coinsurance after the deductible for primary care visits. Other plans will pay 100% after the deducible is met. Some plans have implemented a combination approach: $30 co-pay and 30% Coinsurance after deductible is met for primary care visits.
Prescription coverage has added to the confusion. Most of the drugs on the plan’s formulary have fixed co-pays. Formularies are the same across metal levels. If the drugs are not on the formulary there is generally a 30% to 50% co-insurance after the deductible is met (which may be included in the overall deductible or a separate prescription drug deducible)
Comparing the same provider plans as an example – Bronze vs. Gold. The Bronze plan costs around $287 per month and the Gold around $375. Bronze has a $6,300 deductible and the Gold a $2,500 deductible. For a non-preferred brand name drug, the Bronze plan will pay the entire cost of the drug after the $6,300 prescription drug deducible is met, while the Gold plan in require a 35% coinsurance after a $500 prescription drug deducible is met. Add to the fact that many drugs will require pre-approval and others will require step therapy, this is a very confusing situation for consumers. The determination of which plan will work best for which consumer becomes very difficult.
The overall idea is greater cost sharing imposed on the consumer, which presumably will lead to greater cost savings through more frugal utilization. Consumers will have to budget not only for the premium payments but also for the out-of-pocket costs associated with utilization of the plans. For the health care providers, it will mean a great portion of their fees coming directly from the patient. Only time will tell which of these plans will remain on the Marketplace and whether they will effectively control health care costs. And more importantly for all concerned, what the impact will be on health and wellness.
