**Let me start this post by being the first to state that I am only speaking on my personal experiences of reviewing the plans, and specifically the 2014 plans from when we were writing the ‘Healthcare Woes’ report. As I am writing this now I am meandering through the current enrollment site to see what changes from 2014 to 2015 has brought us as seen by a casual observer. The notes that will be listed here will be what I have gathered from feedback over the past year from patients and some providers, pitfalls seen in the 2014 plans, and just good general resources. These notes do not reflect any official NOVA ScriptsCentral stance but will hopefully be used to find the best coverage plans for each individual’s needs.**
NOVA Scripts does not serve patients with prescription insurance, so the upcoming ACA enrollment on November 15th is something we view with bated breath. It is not that we don’t want patients to have affordable healthcare access, because we do. In fact our ideal world is where everyone has adequate healthcare coverage so that we don’t need to be here, but we fear that some ACA plans may once again put more patients in a coverage black hole. We want our patients to be insured, and receiving top notch care, the question is, are the plans they can afford likely to do that?
First and foremost why would getting insurance create a coverage hole, insurance should prevent that, right? Yes, theoretically, but we found in the 2014 bronze plans and a brief review of the 2015 plans that while the monthly premiums are low and the co-pays are either free or at a low charge they only kick in after the deductible has been paid. On average the bronze level deductibles are $6,000 per person. This means not only is the patient paying anywhere from $100-200 a month for premiums they are expected to pay $6,000 up front before they see any benefit from their insurance. If you were asked to pay $1,500 cash every time you went to the pharmacy would you still buy your insulin? Lovenox? Any medication?
Why is the deductible that high you ask? Because the average chronic condition costs providers about $6,500 a year to treat. These plans put these costs back on the patients, and unfortunately these patients are the ones that can afford it the least. Additionally because these patients have insurance they are now excluded from being seen at most free clinics. So, things to review when looking at plans, especially the bronze plans:
- What is your monthly premium after your tax credit? Can you afford this knowing that you will have to pay more cash for your first few doctor and pharmacy visits.
- What is your deductible? Can you pay on the spot without reimbursement if you go to the doctor? The pharmacy?
- What are your out of pocket costs (often this is the exact same as the deductible or a few hundred dollars more)? How many co-pays are you expected to pay once your deductible has been met? Can you afford this?
- When do your co-pays come in? What are they? What are the exclusions?
- Will you be charged if you try and drop your insurance early? In the 2014 plans I only saw one plan that had this asterisk but just incase it never hurts to check.
- Will this affect your children should they have CHIP? Read the fine print. Make sure you understand the plan in full. Can you call someone who is more familiar with insurance to help? How about a local clinic that is doing registrations?
- Are the providers that take this plan even in your area? Do you have the time to take off work to visit an in-network provider? How about a way to get to their office?
A lot of the feedback that we were getting is that patients, getting insurance for the first time didn’t understand that they would be expected to pay for both a premium and the deductible/co-pay. They were not aware of their prescription’s costs when the insurance was not covering it. For example some types of insulin (a two to three time a day injection) can cost more than $1,000 a vial and you would need multiples of these for a month. These patients unable to turn to the clinics chose to not see the doctor or get their medications as they couldn’t afford that $6,000 deductible. This means if they were to have to go to the ER the community would bear the brunt of these costs. It is cheaper to keep people healthy than let them get critically ill.
If you or a friend or a patient are going to start looking at ACA plans there are good ones out there. Just make sure they do their research and understand the limits. Make sure they understand the associated costs. Just because the Bronze level plans say 60% coverage and have the most inexpensive premiums, doesn’t mean it is the cheapest in the long run (in fact Bronze plans are closer to catastrophic coverage than anything) and you might pay more in the end. Don’t be afraid to ask questions from your local clinic or whomever is doing assisted registrations near you.
Kaiser has a good resource to test insurance knowledge http://kff.org/quiz/health-insurance-quiz/
If you have basic questions on ACA the website has laid out a resource page https://www.healthcare.gov/get-answers/
Good luck and stay healthy.