On Saturday, a new round of open enrollment starts for the Affordable Care Act. The health insurance exchanges will remain open until February.
This is a time for celebration. After all, millions of Americans, including those with disabilities or pre-existing conditions, will have the opportunity to buy quality, affordable health coverage.
But these people will have to find plans that meet their health needs and are in their price range. Unfortunately, many people are finding it difficult to get the information necessary to avoid unexpected expenses and restricted access to drugs, procedures or other vital health services.
People who buy into plans during the enrollment period will technically be "insured," but they may not have the coverage that they believe they are paying for. They may be hit by unforeseen costs and end up in a financial bind. State or federal health officials need to make sure these plans are delivering on the law's promise to expand access to high-quality, affordable health coverage.
Plans come in four "metal" levels — Bronze, Silver, Gold and Platinum — featuring different premiums, deductibles and co-pays. Among the existing 7.3 million exchange enrollees, the Silver plan is the most popular, covering about 62 percent of them.
Silver plans use a tiered ranking system for drug coverage. Each tier requires a different level of cost-sharing by the plan holder. For instance, a drug on the lowest tier might only require a $20 co-pay while a drug on the highest tier may demand patients to pay a third or more of the total prescription cost.
A June 2014 report from Avalere Health reveals that some insurance plans place all prescriptions for certain classes of drugs on the highest possible tier, which requires the highest out-of-pocket costs.
Fully 39 percent of Silver plans require co-insurance payments of 40 percent of the cost or more for all drugs in at least one core medication class. And over half of the plans have co-insurance rates of at least 30 percent for all drugs in at least one class.
This means that for many people, their out-of-pocket expenses for the most effective, innovative pharmaceuticals will be burdensome.
The second big problem with plans is their lack of transparency. Too often, insurance policies are written in a manner that obscures key information on benefits and formularies. That often leaves patients stuck with unexpected bills.
Exchange officials need to establish an efficient, easy-to-access appeals process that enrollees can use in the event they believe they are inappropriately denied coverage. And the insurance websites need simple interactive tools for people to compare coverage options. The Medicare Part D prescription drug program has such a feature, and it's proven hugely helpful to seniors.
The third major concern is that states, and the plans they offer, do not clearly or uniformly define what it means to provide robust coverage for "habilitative" services.
Most people are familiar with "rehabilitative" services — they are services meant to help a person regain a skill lost to illness or injury. Habilitative services, on the other hand, are pro-active procedures to prevent a serious condition from developing in the first place or to teach a skill never learned. For example, a physical therapist may work with a child with cerebral palsy to help him learn to walk.
And while the Affordable Care Act counts habilitative services among the Essential Health Benefits, the federal government has opted not to define the scope of services that must be included in this benefit category.
As a result, many exchange insurers have chosen to offer spotty coverage for habilitative health care — or none at all. Some people have to foot the bill for these services. And those who can't are forced to forgo important care. That, in turn, could cost the health care system a lot more money over the long-run — children can develop potentially preventable conditions requiring significantly more expensive and invasive in-patient treatments.
This upcoming open enrollment period is the perfect opportunity for federal officials to improve the exchanges. The enrollees' biggest battle should be against their disease or condition — not their insurer. Plans should be more transparent about cost features and empower enrollees to make better informed decisions. Moreover, health care officials need to clearly and uniformly define benefit requirements — such as those for habilitative care — to deliver the full impact of these services to patients.
Lawmakers need to improve plan benefits so that the exchanges can fulfill their mission of extending high-quality, reasonably priced health insurance to millions of Americans.