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3 things to know about PPACA World deductibles

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Many of the new Patient Protection and Affordable Care Act (PPACA) major medical plans are more generous than they look.

They may have deductibles of up to $6,600 for an individual and $13,200 for a family, but many of them cover in-network office visits without requiring patients to meet the deductible.

Analysts at Breakaway Policy Strategies look at how PPACA plan deductibles actually work in a report on physician visit cost-sharing published by the Robert Wood Johnson Foundation and based on a large batch of 2014 and 2015 health plan data posted on the foundation’s website. 

The full spreadsheets include data on all silver-level PPACA exchange plans.

The Breakaway analysts prepared separate analyses based on silver exchange plans in the 10 states with the highest PPACA exchange plan enrollment: Florida, California, Texas, North Carolina, Georgia, Pennsylvania, New York, Virginia, Illinois and Michigan.

See also: Where health care consumerism is headed & what that means for brokers

For a look at what the analysts said about deductibles in the physician visit cost-sharing report, read on.

A patient talks to a doctor

1. A majority of silver plans pay for ordinary in-network sick care before an enrollee has met the deductible.

Analysts found that, in the 10 states they studied, only 28 percent of the silver exchange plans require patients to meet their deductibles before getting coverage for primary care provider office visits.

That’s down from 30 percent in 2014.

In most of the plans studied, enrollees can get coverage for a sick visit to an in-network primary care provider without meeting the deductible, by paying a co-payment, a coinsurance amount or both a co-payment and a coinsurance amount.

In-network primary care co-payments in the 10 states ranged from $5 to $60.

Coinsurance percentages ranged from 20 percent to 50 percent.

Silver exchange plans were more likely to impose deductibles on in-network specialist visits, but not that much more likely: The percentage of silver exchange plans imposing deductibles on in-network specialist visits in the states studied has dropped to 39 percent this year, from 41 percent in 2014.

See also: Avalere: Exchange plan out-of-pocket costs vary widely

Confused child

2. Even the Robert Wood Johnson Foundation analysts have had trouble summarizing how plans handle deductibles in a clear, easy to analyze fashion.

The analysts gave the deductible structure information in spreadsheet columns with headings such as “In Net Work Medical Deductible – Individual – Has Multiple Tiers?’ and “Integrated Deductible – Individual – In-Network.”

See also: DaVinci on health care


3. Consumers who want to know if a plan offers pre-deductible coverage have to dig deep into plan Summary of Benefits and Coverage (SBC) notices and plan brochures.

HealthPocket, for example, lists a gold plan in the Kansas City, Mo., with premiums that start at about $285 per month.

The plan has a $2,500 deductible. The SBC states “$25 copay/visit” for “Primary care visit to treat an injury or illness” under the heading “Your Cost If You Use a Network Provider.” But the SBC does not say whether the patient has to satisfy the deductible before being able to get in-network sick care, or if the patient has to pay the $2,500 deductible first, and then can get sick care visits for a $25 co-payment.

The carrier’s own brochure describes how the plan covers in-network and out-of-network diagnostic visits on page 4 of 12.

In the out-of-network column, the carrier says, “You pay 40% [for the diagnostic visit] after you pay your deductible.”

In the in-network column, the carrier says the plan ”pays 100% after you pay a copay per visit.” But the carrier does not explicitly say anything about how the deductible does or does not affect the cost of in-network diagnostic care.

The creators of the SBC and the brochure seem to assume, as a given, that consumers all understand that, if the deductible is not mentioned in a description of out-of-pocket costs, then the deductible does not apply.

See also: 5 top consumer health cost nightmares


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