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According to a recent report from the Department of Health and Human Services, over 8 million Americans enrolled to receive health insurance through the Affordable Care Act’s health insurance exchanges. The expansion of lives covered also comes with expanded benefits: preventive care, lab services, prescription benefits, and emergency services are among the Ten Essential Benefits that must  be included in compliant Exchange Plans. Despite the larger pool of lives covered and the new list of mandatory benefits, the newly insured may face challenges as they begin to use their plans. Starting with their understanding of their health benefits.

Already, many of the healthcare consumers shopping for plans have “found it difficult to get basic information about premiums and plan deductibles” and “don’t know… what benefits the (ACA) plans cover,” according to a 12/31/2013 report from the Kaiser Family Foundation. Imagine their surprise, then, when their new plans don’t cover all of their necessary prescriptions, even though the drugs are on their formulary and their deductibles are met.

Enter prescription co-insurance.

Exchange Plan ChartNearly all plans offered through the Exchange have some sort of co-insurance after a patient hits their deductible. As the premium increases, the co-insurance decreases. The most popular plans, according to a recent CMS report, are the Silver plans: 62% of Americans that enrolled in Exchange plans through 2/14/2014 chose Silver plans, which have a 30% co-insurance for patients.

According to a January 2014 Kaiser Family Foundation report, one-in-three insured Americans had difficulty paying medical bills, and unaffordable medical debt resulting from co-insurance was the largest cause of medical bankruptcy among insured persons (Pollitz, Cox, Lucia, Keith). And 60% of Americans bankruptcies were related to medical care. This issue is likely to grow with the complexity of plans offered through the ACA Exchanges as nearly 100% of Exchange plans have co-insurance obligations.

Co-insurance is already a challenge for 51% of Americans that have employer-funded plans (iCORE Trend Report). It now poses unintended consequences for the approximately 8 million Americans that are newly enrolled via the Affordable Care Act. 16% of Americans are already under- insured according to the Commonwealth Fund Biennial Health Insurance Survey, with the largest reasons being not premiums but deductibles and co-insurance. Consumers now have affordable premiums, but will face challenges dealing with the auxiliary costs.


What can be done to assist these patients in getting the treatment they need?

The Affordable Care Act will likely increase the number of insured by 15+ million by the end of 2014, which includes the 8 million newly enrolled plus those included under the Medicaid Expansion. These patients, however, may face challenges when attempting to use their benefits. Patients will increasingly turn to manufacturer hub services as they attempt to navigate their benefits as treatments are prescribed. A huge opportunity awaits those who are willing to tackle the, sometimes hidden, challenge of co-insurance.


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