Disease Information & Support


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The basics

The open enrollment period for the 2016 plan year will begin in the fall.

Once again, you will want to comparison shop for your health insurance coverage, which is divided into four tiers: platinum, gold, silver and bronze. The lower-level tiers, including silver and bronze coverage, have lower premiums, but they also have higher out-of-pocket costs for consumers. To put these options in perspective, employer-provided insurance plans often have cost-sharing and out-of-pocket costs similar to gold and platinum marketplace plans.

For information on enrollment, go to www.healthcare.gov

Patients with significant medical needs should be aware of the out-of-pocket costs associated with bronze and silver plans

The ACA is structured in such a way that bronze and silver plans feature lower premiums but higher out-of-pocket costs for patients.  Patients should be sure and look at all of the out-of-pocket costs associated with these plans at the lower metal tiers, especially at the lower metal tiers.  They will likely include high deductibles, sometimes as much as $5,000 or $6,000 at the bronze level.  Carriers differ regarding whether or not medications are subject to the deductible, which is another key feature to ask about. 

If you rely heavily on products that are a part of the pharmacy benefit, also look for whether these plans have co-insurance, which requires you to pay a percentage of the cost of the drug or service, which can add up to hundreds or thousands of dollars per month.  As a cancer patient, or any patient with high cost medical needs, this quickly becomes unaffordable. 

Below is a look at a handful of states and how plans in those states price specialty drugs for patients in a bronze plan as well as in a silver plan using 2014 information.

The chart highlights the risks associated with bronze coverage. In every state here except New York, high patient co-insurances are prevalent in bronze coverage.

There is a maximum annual out-of-pocket cap which applies to the new marketplaces. In 2015, this maximum out of pocket is $6,600 for individual coverage and $13,200 for family coverage. While this does offer some basic protections against catastrophic debt, it also is limited to in-network services as well as pharmacy products that are on formulary, making it even more important that you know exactly what is covered by your plan.

Milliman Report on Healthcare Exchanges in Seven States

As part of LLS's efforts to help educate patients about the Affordable Care Act, we commissioned a report that analyzed 2014 individual designs, coverage benefits and premiums for policies sold on seven state health insurance exchanges - California, New York, Florida, Texas, New Jersey, Michigan and Washington. Narrow networks and high cost-sharing are among the concerns raised by the report. Click here to view the full Milliman Report on Healthcare Exchanges in Seven States.


last updated on Monday, March 02, 2015

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