Tag Archives: co-pay

Lost in the Marketplace: Thoughts on the ACA Exchange


Like many of you, I have been unable to apply for an insurance policy on the Marketplace that opened October 1.  That was also the start of “open enrollment” at my work, and I was hoping to see if there was a cheaper option for my family available with similar coverage, even though I would not qualify for a subsidy.  I also wanted to be able to give you more detail about the process and possible pitfalls by trying it myself, since I didn’t have time to train as a navigator.  My window of choice closed for a year, and I gave up trying to log in to stay out of the way of those still trying. 

 

Twice, I got a user name and password and was sent an email to complete the registration process.  Although I clicked the email link as quickly as my fingers would go, within 10 seconds of receiving it and 30 seconds of completing the password entry, the healthcare.gov site said I was too slow—sorry, go back to the beginning and try again.  Perhaps I would have had to grow up with video games to get the required hand-eye coordination speed? Maybe it was a subtle way to get younger, healthy and well-coordinated sign-ups first?

 

It is possible to look at the available plans for a given county without registering—in my county, for an individual/ family policy, I would have a choice of BCBS or Humana.  There is no link within the site to provide nitty-gritty details though.  To get those on your own, you have to apply.

 

I’m going to recommend you work with a navigator unless you are very well versed in health insurance policies.  Be very careful of fraud and check the credentials of whoever you are working with.  Here are some factors to consider.  Remember that the 60% cost coverage on bronze policies and 70% for silver does NOT mean it will work out that way for you personally.  All that means is that for a “typical” subscriber, the insurance will pay 60 or 70% of the total covered services after the premium.  From what I am hearing, the costs to subscribers will be front loaded in the form of significant deductibles that must be paid before the insurance kicks in.  I would advise not selecting a deductible of an amount you don’t have already in savings.

 

If you don’t have insurance now, you may be getting some services from a free clinic, discounted/sliding scale service from a physician or clinic, and/or free medications from a Patient Assistance Program.  I know none of these safety net services is ideal and that people with insurance generally have more options than you have right now.  However, you need to know that once you have insurance, these options will no longer be a plan B for you.  You can’t go to the free clinic on a day when you don’t have your co-pay or co-insurance money unless you are going to lie, because the ones I know of only accept uninsured patients. Your doctor or clinic may not be able waive a part of your co-pay or deductible—that is considered criminal fraud in some cases, against their contracts with the insurer.  Every policy I’ve ever had says, in fine print within the manual, that my policy can be cancelled for breaking the contract if I don’t pay my share through co-pays and deductibles.  So you want to check and see if that is in a policy you are considering.

 

Medication co-pays can add up quickly.  If you are getting 4-5 medications through free Patient Assistance Programs, even if they aren’t the most effective ones for your condition—will you have the funds to buy them? Depending on the co-pay tier, you could be shelling out $150 or more a month. If it is possible to view the formularies for the plans you are considering, and find out the co-pays for your medications, I would recommend it.  You need to know that insurers can change their formularies without your permission and without warning.  If you aren’t in an open enrollment period when that happens, you’ll be stuck with it for awhile.

 

If possible, it would be good to look at the provider networks for each plan, for both primary care and specialists you need, and see if they are taking new patients.  Be careful to note if there are restrictions on laboratories and radiology facilities you can use—I have learned there are a couple of new plans that will restrict lab services to only one company, Quest.  You don’t want to go to a non-contract lab for blood work and find out later the bill is fully on you.  If you see mental health providers, check to see if there is a carve-out policy that delegates management to a sub-insurer.  I’ve been told by a navigator this is not an issue with the plans in our county.  These can be a significant barrier to care, in my experience.  Even without a carve-out, check the mental health provider network and ask if your primary care provider can be included—a critical feature to allow initiation of treatment while you are waiting for a mental health referral.

 

If you are uninsured and have significant chronic conditions already being managed through charity services, you may find out that you can’t afford to switch to insurance even with the subsidy and even considering the tax penalty.  Being uninsured is frightening, because the gaps in charity coverage are tremendous and you never know if you will acquire a new condition and be left without help.  At the same time, you do not want to be left unable to purchase ongoing treatment you already know you need.  You don’t want an insurance card you can’t afford to use.  I have seen this happen many times, in person, to families who had insurance and too much income for their children to get Medicaid or AllKids but not enough to pay for services or prescriptions.  It is a difficult decision—don’t make it lightly.

 

If you have no chronic conditions, you may decide it is worth the risk to sign up for insurance.  That’s the function of insurance, as you know—it is a risk pool, where we enter not knowing who will need to use the funds we add to the pot.  We don’t expect to each get back the amount of services we have paid for with our premiums—we don’t even want to, because that would require illness or injury.  The more healthy people who sign up and contribute, the lower the cost for everyone in the pool, and the more total profit for the insurers.  You could be helping other people in your state more than yourself, or they could wind up helping you. 

 

One thing is for sure—we are all, through the forced wealth transfer in the ACA, helping to line the pockets of private insurers and strengthen their position at the lobbying table.  We are taking a large step away from single payer, a public option and even community level grassroots safety nets by doing so.  Ought we to use much time and energy to prop up a plan with such fatal flaws at the core? 

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Filed under Exchanges, Healthcare reform