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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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Under the law, there are special provisions for lower-income Americans who purchase a silver plan but not a bronze plan.  People who earn less than 250 percent of the poverty level -- about $28,700 for an individual -- get extra help from the federal government in the form of lower copayments for doctor visits and smaller annual deductibles.  For the lowest-income residents, that can mean plans with little or no deductible and copayments as small as $3 for primary care doctor visits.

"Be very careful before you take a bronze plan over a silver plan" if you are in the subsidy-eligible income range, said Linda Blumberg, a senior fellow at the Urban Institute. Those earning less than twice the federal poverty level, about $23,000 a year for an individual, get the most help, with subsidies ratcheting down sharply after that.

Consumer advocates say shoppers should consider a wide range of plans -- and not assume that the plan with the lowest monthly premium is the best for them.  Still, finding out about what services -- other than preventive care -- are covered before the deductible is met can take some digging.

Generally, any plan that can be linked with a "health savings account" -- a way to put money aside tax-free to cover medical costs -- will not cover much except preventive care before the deductible is met because of rules governing those accounts. For all other plans, consumers can check insurers' websites for details or log onto healthcare.gov, the federal marketplace that covers residents of 36 states. A new feature added to healthcare.gov shows each policy's monthly premium, annual deductible and the copayments required for doctor visits, drugs and emergency room care.

Plans that list a price for a doctor visit followed by the phrase "after the deductible is met" mean the consumer must pay the full deductible before getting doctor visits for a small copayment. Additional information can be found by clicking the "details" button and reading the summary of benefits. Consumers can also call insurers directly or look up the information under the policy name on an insurers’ website.

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communications organization not affiliated with Kaiser Permanente.

Fri, Dec 20 2013

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