While Affordable Care Act health plans offer better protection for those with chronic health issues, a recent analysis by Avalere Health found that many may still find themselves “underinsured,” spending more than 10 percent of their income on medical care beyond their monthly premiums -- even if they qualify for cost-sharing subsidies on the health insurance marketplaces, writes KHN.
According to the National Health Council, which advocates for people with chronic health conditions, the structure of out-of-pocket costs and covered benefits will create "serious problems" for some.
The potential trouble spots include prescription drugs; specialist care, including that provided by academic medical centers; and services such as physical therapy that typically require a course of treatment over weeks or months, experts told KHN.
The Avalere analysis found that many chronically ill people, especially those in Bronze or Silver plans that offer less generous coverage, will likely reach their out-of-pocket maximum every year. Navigators and insurance agents in Miami-Dade have been steering applicants away from Bronze plans in particular because of their out-of-pocket costs.
Chronic conditions can cost thousands of dollars a month for medications to maintain effective treatment. The new health exchange plans place many of those drugs in specialty tiers with as much as 50 percent co-insurance. If your treatment costs $1,000 or more a month and the medication is in that tier, you would be responsible for half the cost, over and above your plan's monthly premium.
Access to specialists and to academic medical centers with the necessary expertise will also be more difficult where insurers have opted for a narrow network of doctors and hospitals in order to keep premium costs low. 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, reports KHN. In Miami-Dade, Humana's exchange provider network includes only four hospitals.
Again, people who need specialist care from an excluded provider will bear 50 percent of the out of pocket costs, provided the plan allows them to go out of network. HMO plans that do not cover providers out of network require the consumer to bear the full cost if they do. Read more.