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Health Insurance & Affordable Care Act

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

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Meeting the deductible before most coverage kicks in is common in the individual market, but differs sharply from job-based health insurance.  More than three-fourths of the insurance plans offered to Americans with coverage through their jobs pay a substantial chunk of the cost of doctor visits without the worker having to meet the annual deductible first, according to the annual survey of employers by the Kaiser Family Foundation. (KHN is an editorially independent program of the foundation.)

All Plans Must Cover Preventive Services

Under the law, Congress granted insurers leeway in how they design their plans, so long as bronze plans cover at least 60 percent of the costs of a typical policyholder, silver plans cover 70 percent, gold plans cover 80 percent and platinum plans cover 90 percent – with consumers on the hook for the remainder.  Gold and platinum plans were not included in the eHealth/KHN analysis because they generally cover more services with less cost-sharing by consumers. 

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.

Fri, Dec 20 2013

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