There are currently concerns that those needing substance use disorder (SUD) treatment cannot access treatment because of high deductibles and co-pays. While this may certainly be true, there may be opportunities and considerations available to an individual that can help to address this issue:
- Open enrollment to purchase insurance in the federal marketplace is from 11/1/16 – 1/31/17. Because of changing plans and current offerings, even those individuals who have previously signed up for a plan should be encouraged to explore the marketplace for insurance options that might better serve their needs; offering better coverage at a better price.
- Understand that low premiums can be deceiving; generally plans with lower premiums have higher co-pays and deductibles and can result in higher overall costs.
- The plans on the marketplace are arranged by metals: bronze (60%); silver (70%); gold (80%); and platinum (90%). The percent figures refer to the actuarial value of a plan, which means the percent of costs the insurance company is projected to pay for the care of all of their enrollees after premiums are paid. So, for a bronze plan, an insurance company is expected to pay 60% of costs after the premium, leaving the consumer with 40%. While a bronze plan may seem like the most affordable as far as premium is concerned, the overall cost to a consumer could be significantly higher once they use health care services.
- The federal government offers premium assistance for those individuals and families who meet financial eligibility requirements (400% federal poverty limit): $60,000 for individuals/$97,200 for a family of four. This results in a premium reduction in correlation with income. Premium assistance is available for any plan on the federal exchange, but the amount of assistance is based on a household’s income and is relative to the cost of the silver plan.
- Cost sharing assistance is available to help cover the costs of co-pays and deductibles for individuals earning between $15,800 – $47,520 and families of four earning between $32,319 – $60,000. Cost-sharing assistance is only available to consumers who choose a silver plan.
(Note: the federal government does not offer assistance subsidies for employee-based coverage, which may also have high deductibles and co-pays).
- Unfortunately, while many individuals in need of SUD services would qualify for the federal assistance subsidies applicable to premiums, co-pays, and deductibles, it is believed that when purchasing insurance from the marketplace they choose the least expensive option (a bronze plan). This makes them ineligible for the cost-sharing financial assistance and, in the long run, costs them more and provides them with coverage that they cannot afford to use.
- For this reason, all stakeholders (SCAs, case managers, treatment providers, recovery organizations, other advocacy groups, etc.) should encourage individuals who obtain insurance from the marketplace to explore their options during open enrollment and engage the free services of a navigator (an individual who can assist in determining the best insurance options for a particular person), and utilize the Total Cost of Care Calculator.
- Available resources:
Navigators/Certified Application Counselors
Pennsylvania Health Access Network: 877-570-3642
Pennsylvania Health Law Project: 800-274-3259
PA Insurance Department Resources:
Informing and assisting individuals in obtaining the right insurance coverage/plan is paramount to helping them access SUD and other services at an affordable cost, and assuring that agencies are engaged in the most effective methods and responsible use of available funds in providing assistance to those who need it.