Low Premiums May Mean High Out-of-Pocket Health Costs

If you buy one of the less-expensive insurance plans sold through the Affordable Care Act’s marketplaces, you may be in for a surprise: Some plans won’t pay for doctor visits before you meet your annual deductible, which could be thousands of dollars.

“This could be the next shoe to drop, as people don’t realize that if they’re buying a bronze plan, they may have to pay $5,000 out of pocket before it contributes a penny,” Carl McDonald, senior analyst with Citi Investment Research, said at a conference last month in Washington.

Experts say some new enrollees will be discouraged from seeing doctors if they have to pay the full charge rather than simply a copayment. In Miami, for example, 40 percent of bronze plans require consumers to pay the full deductible before coverage kicks in, according to an analysis by online broker eHealthinsurance.com, a private online marketplace, for Kaiser Health News. The average deductible among the examined bronze plans in Miami is $5,735.

Patients in those plans who haven’t yet met their annual deductibles would have to pay the full cost of the visits, unless they were for preventive services mandated by the law. A typical office visit can run $65 to $85, while more complex visits may cost more.

People who buy their own insurance have always had to pay a set annual sum, called a deductible, before policies begin paying their claims. But first-time insurance buyers may not realize they’re on the hook for those costs before benefits kick in, and might choose plans based solely on the monthly premiums.

Bronze and silver plans, which have the lowest monthly premiums but typically some of the highest deductibles, are the most likely to require consumers to spend that amount themselves before the insurer pays any claims.

There’s no nationwide data on how many plans do that. But in seven major cities, including Miami, half of bronze plans, on average, require policyholders to meet the deductibles before insurers will help with the cost of doctor visits, the eHealthinsurance-Kaiser Health News analysis found.

Silver plans, which generally have higher monthly premiums than bronze, are more generous, with more than three-quarters paying for doctor visits before the deductibles are met. The analysis included most or all of the plans available through the health law marketplaces in Atlanta; Philadelphia; Dallas; Tampa-St. Petersburg, Fla.; Miami; Chicago; and Phoenix.

In Florida, 90 percent of silver plans offered in Tampa and 89 percent in Miami allowed coverage for at least some doctor visits before the deductibles were met.

Meeting the deductible before most coverage kicks in is common in the individual market, but it differs sharply from job-based health insurance. More than three-fourths of the insurance plans offered to Americans with coverage through their jobs pay a substantial chunk of the cost of doctor visits without the workers having to meet the annual deductible first, according to an annual survey of employers by the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)