The recession is forcing consumers and their insurance advisors to face a troubling reality: Even many Americans with good incomes and solid health insurance can have large gaps in their benefits.
A while back, when the housing market was strong and applying for credit card limit increases was easy, relatively high-income families facing expensive health problems sometimes coped by taking out home equity loans, or maxing out credit cards.
Today, the real estate slump and credit market crash have reduced those options.
Meanwhile, “group health insurance plans at work aren’t as comprehensive as they used to be, which means employees are on the hook for more out-of-pocket expenses not covered by their health plan,” says Tom Gilligan, a senior vice president at Colonial Life & Accident Insurance Company, Columbia, S.C.
Health care experts say strategies for helping clients cope with health benefit gaps include prevention, insurance products and creativity.
Gaps are growing partly because carriers, employers and consumers all are looking at increasing out-of-pocket costs as a method for holding down premium costs.
Gaps also are growing because carriers, employers and government agencies see increasing consumers’ out-of-pocket costs as a tool for encouraging consumers to think about the true cost of health care.
In the U.S., consumers are paying a smaller percentage of health care costs now than they were in 2000, or in 1970.
Consumer out-of-pocket spending amounted to just 26% of the 2007 private health care payments, down from 30% in 2000, and down from 62% in 1970.
Mercer, New York, a unit of Marsh & McLennan Companies Inc., New York, estimates that the typical deductible for an individual in an employer-sponsored preferred provider organization plan is now about $1,000.
Typical out-of-pocket maximums are $2,000 for single coverage and $4,000 for family coverage.
But many families–even those with incomes exceeding 400% of the federal poverty level, or about $80,000 for a family of 4–suffer from medical bill problems when out-of-pocket expenses exceed just 2.5% of family income, according to researchers at the Center for Studying Health System Change, Washington.
A $2,000 maximum would exceed 2.5% of annual income for a single worker earning less than $80,000 per year, and a $4,000 maximum would exceed 2.5% of annual income for a family earning less than $160,000 per year, the researchers write.
The Commonwealth Fund, New York, estimates the percentage of underinsured U.S. residents in households earning more than $100,000 per year rose to 7% in 2007, from just 1% in 2003.
Consultants at PricewaterhouseCoopers L.L.P., New York, have predicted that the underinsured will be attracting far more attention in coming years than in the past.
“In 2009,” the consultants say, “we could see more debts for hospitals, more cost-shifting to commercial plans, and more patients delaying or foregoing care” as a result of underinsurance.
The HSC researchers found underinsured consumers may respond to medical bill problems by doing without mental health care, physical therapy and dental care.
What can insurance advisors tell clients about coping with potential gaps?
Insurance advisors can start by recommending that clients make a serious effort to save and be realistic about their financial resources when choosing plan deductibles and preventive care benefits.
A plan with a $20,000 deductible might be the best option for a client with $20,000 in the bank and a large, generous family, but a bad option for a loner with just $2,000.
Advisors also can encourage clients to look for individual plans or employer-sponsored plan alternatives that use the broadest possible definition of “pre-deductible preventive care.” Some high-deductible plans, for example, may pay for several physician office visits per year with a relatively low co-payment before an insured meets the annual deductible.
Many newer high-deductible plans, including HSA-compatible plans offer special, pre-deductible benefits for efforts to control diabetes and other chronic conditions.
Insurance advisors also should recommend that clients choose, when possible, to sign up for employer-sponsored health plans that apply provider network discounts before deductibles are met. In many cases, applying the network discounts can cut 50% to 80% off pre-deductible bills.
Some of the insurance products that advisors could recommend as gap fillers include long term care insurance, limited benefit “mini medical” plans, hospital indemnity plans, critical illness plans, “medical tourism” discount programs, and reputable drug discount card programs.
LTC insurance is far more than a gap filler, but the CMS National Health Statistics Group says nursing home care was one of the main drivers of a 5.3% increase in consumers’ out-of-pocket health care spending.
Consumers who know they will be using specific types of brand name drugs or “nondurable medical supplies” should consider shopping for discount programs that offer steep discounts on those particular products, because the National Health Statistics Group figures show increases in spending on retail prescription drugs and nondurable medical supplies also contributed to the out-of-pocket expenditure increase.
Limited benefit health plans, mini med plans and critical illness insurance plans can fill gaps resulting from serious illness.
Guardian Life Insurance Company, New York, for example, recently introduced a group critical illness insurance program that can pay a lump sum of up to $50,000 and also can pay up to $500 per day in cash for insureds admitted to the hospital for conditions not covered under the CI plan.
Loyal American Life Insurance Company, a unit of Great American Financial Resources Inc., Cincinnati, sells a hospital indemnity product that pays up to $300 per day for up to 30 days of confinement in a hospital.
When savings and insurance products fail, advisors still may be able to refer clients to health care advocates who can persuade care providers to mark down their bills, or to nonprofit groups such as the HealthWell Foundation, Gaithersburg, Md.
The HealthWell Foundation helps some underinsured clients with family incomes up to 400% of the federal poverty level handle health insurance premiums, co-payments, deductibles and prescription drug coinsurance payments.