Looking for some relief from high out-of-pocket costs at the pharmacy or your doctor’s office?
People who help run the Insure the Uninsured Project in Santa Monica say you may not have to look much further than your own health plan.
The benefit packages of lower-cost bronze and silver-level health plans — sold through the state’s health insurance exchange — aren’t as expensive as they might seem at first, they say.
Carolina Coleman, the project’s research director, and John Connolly, the nonprofit’s deputy director, say that many consumers who focus only on their high deductibles may be missing some gems hidden in their existing policies.
Bronze plans come with a $5,000 deductible. That’s how much you must spend out of your own pocket before getting financial help from your insurer. Silver-level policies have deductibles of $2,000.
That’s a lot of money for most people to shell out on top of the monthly premium they pay for their insurance policy. Experts worry that the initial financial burden is too steep for most patients, causing some to skip needed care.
But Coleman and Connolly say many consumers — as well as insurance brokers and others trained by Covered California to assist them — have minimized or simply missed the fact that bronze and silver plans include access to reasonably priced doctor visits.
“People who purchased bronze and silver-level plans may not realize that many of the outpatient services they need don’t require them to first meet their plan’s deductible,” Coleman says.
“If people don’t realize that these benefits are available to them with relatively limited cost-sharing, they’re not going to take advantage of them,” she says.
Experts have highlighted important details of the most popular plans sold through Covered California that — if overlooked — can cost you.
Preventive services. Many people are now aware that the Affordable Care Act requires most insurers to cover the full cost of many preventive services, such as vaccinations, annual wellness visits, and cancer and other health screenings, with no co-payments or other charges.
However, experts say many people are still confused about their costs when those preventive visits turn into further treatment.
“Your preventive check-up may come without any cost-sharing, but if they find something and you need treatment, that does not come without cost-sharing,” says Micah Weinberg, senior policy advisor to the Bay Area Council, a public policy advocacy organization in San Francisco.
Bronze-level plans. Many people are unaware that all bronze-level plans sold through Covered California must allow for three outpatient visits a year, and you are not required to first meet your plan’s $5,000 deductible. Instead, you pay a $60 flat-rate fee, or co-pay, at the time of your visit.
“A lot of people can take care of their healthcare needs in three visits. So if they knew about that, that $5,000 deductible might not be as scary,” Coleman says. “We’re finding across the board that very few people know about this.”
The three visits, for instance, can include a trip to your primary care doctor, a mental health provider or urgent care. After that, you’ll pay for all of your medical services — at your insurer’s negotiated rate — until you’ve met your deductible. If you have a family plan, each member is allowed these three deductible-free visits each year.
Pediatricians are considered primary care physicians for children. That means those appointments are included in the three visits.
Women may have some flexibility too. If a gynecologist “is acting as a primary care physician, they may designate themselves as such with the carrier,” says Patrick Burns, president of the California Assn. of Health Underwriters. However, some plans may not allow that. You must check directly with your plan, Burns says.
Finally, if a preventive screening leads to further treatment that can be provided by your primary care doctor, that visit will count as one of the three visits exempt from your deductible. “As long as you go to a primary care physician for the treatment, it’s definitely non-preventive and would count as one of the three visits,” says Dana Howard, deputy director of Covered California.
Silver plans. These policies, which come with $2,000 annual deductibles, allow you to pay flat-rate co-pays for nearly all outpatient visits — whether to primary care physicians or specialists. Also available without first meeting the deductible are services such as lab work, X-rays and generic medications.
The one exception is if you’ve purchased a plan that comes with a Health Savings Account. These are accounts that allow you to set aside money, tax free, to spend on a wide range of medical expenses.
“With an HSA you don’t have any first-dollar help without having to first meet the plan’s deductible, except for the preventive care,” says Carrie McLean, customer service director for the private insurance exchange EHealth.
Health plan extras. Most plans offer additional services at no extra cost. “These are things I think people don’t realize,” McLean says.
Benefits vary by insurer, but some, such as Kaiser Permanente, give you access to free phone appointments with a doctor.
Nurse advice telephone lines also are often made available to policyholders with medical questions or concerns.
And most insurers offer wellness coaching programs that help you with weight and stress management, nutrition, sleeping and smoking cessation, among other health concerns.
Take the time to learn. With out-of-pocket costs rising, Weinberg of the Bay Area Council says, patients need to take a more active role in navigating their benefits.
“People will come into the doctor’s office with pages of printouts from WebMD about what condition they think they have. If consumers are doing that much to educate themselves about their potential condition, they should also do something to educate themselves on their benefits and be armed with that information when you go to the doctor,” he says.
Like many healthcare advocates, Coleman and Connolly from Insure the Uninsured Project worry that high out-of-pocket costs keep consumers from getting the care they need.
That’s why they’re working to make sure that the generous aspects of insurance policies are understood. Then, Connolly says, “the deductible becomes a lot less scary.”
Zamosky is the author of “Healthcare, Insurance, and You: The Savvy Consumer’s Guide.”