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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

WebMD News from Kaiser Health News

By Julie Appleby

Fri, Dec 20 2013

If you buy one of the less expensive insurance plans sold through the health law’s marketplaces, you may be in for a surprise. Some plans will not pay for a doctor visit before you meet your annual deductible, which could be thousands of dollars.

"This could be the next shoe to drop, as people don't realize that if they're buying a bronze plan, they may have to pay $5,000 out of pocket before it contributes a penny," said Carl McDonald, senior analyst with Citi Investment Research, speaking at a Washington, D.C., conference last month.

Experts worry that some enrollees will be discouraged from seeing doctors if they have to pay the full charge, rather than simply a copayment.

Those who’ve bought their own insurance have always had to pay a set annual sum, called a deductible, before policies begin paying their claims.  But first-time insurance buyers may not realize they’re on the hook for additional costs before benefits kick in, and may choose a plan based solely on the monthly premiums.

Bronze and silver plans -- which have lower monthly costs but typically, higher deductibles -- are the most likely to require consumers to spend that amount themselves before the insurer pays any claims. There is no nationwide data on how many do that. But in seven major cities, half of bronze plans on average require policyholders meet the deductible before insurers help with the cost of a doctor visit, according to an analysis by eHealthinsurance.com, a private online marketplace, for Kaiser Health News. Patients in those plans who haven’t yet met their annual deductible would have to pay the full cost of the visit, unless it was for a preventive service mandated by the law. A typical office visit can run $65 to $85, while more complex visits can cost more.

Silver plans, which generally have higher monthly premiums, are more generous, with more than three-quarters paying for doctor visits before the deductible is met. The analysis included most or all of the plans available through the health law marketplaces in Atlanta, Philadelphia, Dallas, Tampa-St. Petersburg, Miami, Chicago and Phoenix.

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. 

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