A lot of “Buyer Beware” on the New Offered Health Plans Twisting Existing Options
Fueled by consumer frustration with high premiums and deductibles, two new offerings promise a means for consumers to take control of their health care costs. But experts say they pose risks.
High premiums and major deductibles push While they are such suitable, these progressive say they aim to ease the consumer’s frustration by harnessing the growing availability of price information or patients’ newfound comfort with online health services, people can shop around for lower premiums and deductibles.
One such plan, from Sidecar Health, pays for you to visit a doctor and lets you shop around for the best deal. Another option is Antidote Health- it's not health insurance but provides primary care online with a small monthly fee.
While the image the plans present is one of the consumers taking control of their health care costs, the reality is likely the opposite. What the plans present, according to Dania Palanker, assistant research professor at Georgetown University's Center on Health Insurance Reforms, is one of the consumers taking control of their health care costs.
That’s because these are not affordable care act plans, they do not provide comprehensive medical insurance and it could also leave patients responsible for hundreds and thousands of dollars if benefits cover only part of a medical bill or if limited to another plan limitation.
Many consumers have been unhappy about ACA plans because they are "too expensive" or the out-of-pocket costs are too high, said Mike Smith from The Brokerage. He also mentioned that doctors don't accept them, these plans lower premier are possible because the plans coverless ACA (Affordable Care Act plan). The standard benefits package does not include maternity care and they have no annual limit on how much you can pay out of pocket, both of which are not allowed in ACA plans.
Sidecar customers find the reimbursement they received for care to be less than their charges, the antidote does not cover lab work, X-rays, hospital care, or expensive drugs.
Sidecar, a company with its Access Plan licensed for sale in 17 states, has added a layer of pricing information to what is known as fixed-indemnity plans. Such plans pay the policyholder a flat rate and usually consist of dollar amounts based on types of care (for example doctor visits or hospital days).
Sidecar provides information about an individual's health care services including 170,000 service prices based on the average cash price in patients' area for each service. This includes most routine doctor visits and lab work as well as line-item charges found in surgical fees and hospital care.
Sidecar is a platform that tells patients upfront what it will pay toward their medical visit. They can then use this data to shop around for the best care and prices. Patients pay any difference between the Sidecar allowance and the actual charge. Conversely, if the patient can get it for less than Sidecar's rate, the enrollee pockets the difference.
CEO Patrick Quigley sees his company as a part of a growing effort to harness the growing availability of price information, one that may prompt reluctant Americans to comparison shop.
"We're building a product around transparency and control, turning patients into purchasers," he said.
"Indemnity insurance can be useful in filling coverage gaps," Palanker said, but it "isn't major medical health insurance."
When a person selects, for example, $50k coverage but later faces a $100k hospital bill after being in an accident or contracting COVID-19. They are responsible for the difference.
Sidecar says that because premiums are based partly on the total coverage amount, they vary. However, the most common monthly premium ranges from $200 to $300.
Candidates are required to answer some health question, and those who weigh upto 300 pound or they have any of 13 health conditions are rejected.
Quigley says that the lack of a network and upfront prices frees people to choose any doctor, hospital or clinic, but it can also turn out to be that the services are not available and there no guarantee that the provider will accept Sidecar benchmark price as payment in full.
For complex treatments like sugeries, sidecar makes it easy for members to get information about specific treatments in advance that are complex, then email or fax the estimate with all expected charges to Sidecar, they do the math and determine how much you would pay.
Stacey Pogue is a senior policy analyst with Every Texan, a policy and research group in Austin. "Consumers are not used to saying, 'I need every code you're going to bill,'" she said, referring to the hospital billing codes that everyone needs these days."For a really sophisticated consumer who understands indemnity insurance and cash prices and negotiating, this could be a good product, but I just don't think there are that many such consumers."
There's also no way to shop around in an emergency.In those cases, Sidecar says it will step in after the fact and negotiate directly with the hospital. It aims for "a reasonable charge." Quigley said
Even proponents, including The Brokerage's Smith, said Sidecar may not be the best choice for everyone. Clients who choose it must educate themselves on how it works, especially its limitations, he said.
Consumers buy Sidecar's Access Plan online from the company or through participating brokers like Smith rather than buying through federal or state marketplaces offering ACA insurance
Sidecar Health announced that it has obtained approval in order to sell an ACA plan there in the beginning of November. The coverage will start from next year, because this version must meet all the law’s requirements — including accepting applicants with preexisting health conditions, posing no dollar limits on how much care it will cover and capping enrollees’ out-of-pocket costs — its premiums in some cases may be higher than the Access Plan’s.
Unlike ACA offerings from other carriers, this one will have no set network of doctors and hospitals and the consumers will shop around, armed with plan price infromation.
Antidote is sold in 8 different states. Each month, individual memberships start at $35 and family memberships are available for an additional fee of $59.
When Antidote Co-founder Ben Enosh first described the program's fees as "premiums," he later corrected himself to explain that it has a one monthly fee, at a lower price point than insurance, which requires premiums plus deductibles and copays.
Carefirst, a digital healthcare company which is not insurance, provides technical and administrative support to physicians. That's why it is not licensed by many state regulators as an insurer.
The plan is similar to “direct primary care” because patients pay a monthly fee to their local doctor for all of their basic health and primary care needs, unlike most of these other programs, Antidote is all online. The patients may not see the same physician/doctor every time and that the physician might be in another state.
Antidote has a network of 50 doctors in a variety of fields, some who are investors. Enosh said, Before an online visit, patients answer a health questionnaire, which takes about 10 minutes, he added. The data is analyzed using an algorithm by doctors to determine what might be going on. The technology has helped shorten online visit time to six minutes, the doctor said.
Antidote's service provides primary care visits only, but enrollees are informed of cash prices available at nearby labs. The online terms of the plan show there are limited visits for individuals, which will cost $15 per visit if it exceeds patient’s allotted number.
Additionally, its "no extra fee" drug coverage only covers 80 types of medications which may be sufficient for minor health problems but not cancer or other major conditions. Patients would need to pay for those themselves.
