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Consumers Beware: Not All Health Plans Cover A Doctor's Visit Before The Deductible Is Met


All new plans must cover some defined preventive services with no copayment by the consumer and without having to meet the deductible first. Those include some vaccinations, mammograms and other cancer screenings, contraception, including birth control pills, and periodic physicals. But prevention services do not include treatment for an  illness, such as the flu. Charges could also apply if, during a preventive care visit, the patient is also treated for a medical condition or a minor injury. In addition to doctor visits and preventive care, some plans may also offer limited coverage for some prescription drugs.

So policyholders get some coverage simply by paying their monthly premiums. But “consumers need to look closely at plan design,” said Nancy Metcalf, senior program editor at Consumer Reports.  “If you have someone without a lot of money and they have a $4,000 or $6,000 deductible before anything [beyond preventive services] is covered, I have concerns about access to care.”

Sixty-four percent of bronze plans offered in Dallas, for example, require policyholders to meet the full deductible before insurance coverage kicks in, according to the eHealth/KHN analysis, which included all insurers except one, Molina Healthcare.  The average deductible in those plans was $5,400, according to the data provided to eHealth by insurers.

In Philadelphia, by contrast, 33 percent of bronze plans require policyholders to pay the deductible first, the smallest percentage among the cities studied.  The average bronze deductible there was $5,689.

Among silver plans, the analysis showed that far more provide some coverage before the deductible is paid.  Of 14 plans examined in Chicago, for example, only one required the deductible to be fully met before the consumer could see a primary care doctor for a small copayment.  All but one insurer, Land of Lincoln Mutual, were included in that analysis.

 In Florida, 90 percent of silver plans offered in Tampa and 89 percent in Miami allowed coverage for at least some doctor visits before the deductible was met. In Florida, however, the database did not include one major insurer, Florida Blue, which has more than 18 plans in the Miami market alone.   Florida Blue did not respond to requests from KHN for information about which of its plans cover doctor visits before the deductible is met.

Don’t Assume Lowest Premium Plan Is Best

Cigna spokesman Joe Mondy said that the insurer sought to offer consumers a range of choices. Some of Cigna’s plans, for example, allow in-network visits with primary care doctors before the deductible is met, typically for a $30 to $45 copayment, while others do not.

"We structured the plans with the recognition that a lot of the new customers have never had a primary care or family doctor," Mondy said. Plans that allow primary care visits for a small copayment are expected to foster doctor-patient relationships, he said.

Fri, Dec 20 2013

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