“What I’m finding with the insurance policies that are available, it’s going to cost you either way,” says Earley.
The gold plan with the best Humira coverage would cost roughly a quarter of their income, says Earley, who is not eligible for tax credits to subsidize his premium costs. But that may be their best option, even with financial assistance from the drug's manufacturer, given the high drug coinsurance charges on the other plans.
Drug costs are perhaps the most often cited coverage concern for people with chronic conditions, but there are others, say experts.
Access to specialists and to academic medical centers with the necessary expertise can be problematic on the marketplaces, where many insurers have opted for a narrow network of doctors and hospitals in order to keep a lid on premiums. A recent McKinsey & Co. study found that 70 percent of the 120 plans it examined offered narrow hospital networks that excluded at least 30 percent of an area’s biggest hospitals. Academic medical centers were generally part of broader plans whose premiums were 10 percent higher than average.
For people who need specialist care, narrow networks can be problematic since the law’s limits on what a patient spends out-of-pocket only apply to in-network care. Dermatologists trained in handling severe psoriasis may not be in network, nor the academic medical centers that some people need for treatment, says Leah Howard, director of government relations and advocacy at the National Psoriasis Foundation.
On the other end of the spectrum, sometimes the out-of-pocket costs for effective treatments such as phototherapy can deter patients who would have to make a copayment for perhaps dozens of sessions.
“We’ve seen people who would prefer to be on phototherapy, but can’t afford $500 in copays over eight weeks, so they end up stepping up to a systemic treatment,” says Howard.
In addition, although dollar limits on benefits aren't allowed, plans typically limit the number of sessions for certain treatments such as physical therapy.
Because of the rocky rollout of the exchange websites in many states, many consumers have found it difficult to get basic information about premiums and plan deductibles, say experts. Many don’t know which providers are in the plan networks or what benefits the plans cover.
“As more and more people become covered and as people start to use their plans, we’ll see if the cost protections in the plans are sufficient, and directed toward getting people the care they need,” says Sara Collins, a vice president at the Commonwealth Fund.
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.
Tue, Dec 24 2013