Deborah Cavallaro, for instance, a real estate agent from Los Angeles, was enrolled in an individual plan that cost her just $293 per month. Under Obamacare, Cavallaro says she’ll have to pay over $400 for coverage she doesn’t need or want. But a higher premium doesn’t tell the whole story: while Cavallaro may spend more each month, she’ll be buying more comprehensive insurance with fewer out-of-pocket costs, better benefits that will cover more and cost her less if she actually falls ill, and much more robust consumer protections.
So before you buy into the sticker shock hysteria, here are four questions you should ask:
1. What does the old plan actually cover? Most of the policies in the existing individual health care market — which are currently issuing notices — offer low premiums, but also come with skimpy benefits and high out-of-pocket costs. These plans often have low limits for outpatient treatment, hospitalization or don’t offer any benefits for procedures like colonoscopy, chemotherapy or mental health treatment. Insurers market these policies to young and healthy people who don’t use their coverage — and never know the true extent of their benefits. (The market is also fairly mobile, with just 17 percent of individual subscribers purchasing the same plan for two years or longer.)
Under the Affordable Care Act, insurers cover 10 essential categories of benefits, offering far more comprehensive coverage than what’s available in most individual insurance plans.
2. Did this person go to the exchanges? Insurers informing policy holders that their health care costs will go up, often direct beneficiaries to their other brand products without telling them about competitive options and prices available through the exchanges. Cavallaro, for instance, got a quote from a broker, but did not explore the available options on her own.
Prices are lowest in areas with the most insurer competition. An analysis from the McKinsey Center for U.S. Health System Reform found that “new entrants into the market make up 26 percent of all insurers,” and “tend to price their plans lower than the median premiums in their market.” The average premium in the exchanges is 16 percent lower than previously projected.
3. Yes, the premium is low, but what are the co-pays and deductibles? This coverage often forces individuals who do use care to meet high deductibles — the amount you pay out-of-pocket before your insurance kicks in — pay high co-pays and co-insurance or limit the number of doctor visits that are allowed. Cavallaro, for instance, must meet a deductible of $5,000 a year and has an out-of-pocket cap of $8,500 a year. The plan covers just two doctors’ visits and each include a $40 co-pay.
As the LA Times’ Michael Hiltzik points out in California, Cavallaro could sign-up for a Silver level plan with a $2,000 deductible, maximum out-of-pocket cost of $6,350, pay $45 for a primary care visit and $65 for a specialty visit — “but all visits would be covered, not just two.”
The health law sets exchange enrollees’ maximum annual out-of-pocket costs at $6,350, and silver plans have deductibles ranging from $1,500 to $5,000.
4. Does this person qualify for subsidies? Americans between 100 and 400 percent of the federal poverty line ($46,000 for an individual, or about $78,000 for a family of three) qualify for tax credits under the law. Six of the 7 million individuals who are expected to sign up for insurance through the exchange will receive an average tax credit of $5,290 per year.
Cavallaro “qualifies her for a hefty federal premium subsidy,” Hiltzik reports and can purchase a silver plan for $333, $40 more than she’s paying now. A cheaper bronze plan would be in the $200s.