By Kristen Lau

Wait a second…you can have health insurance and still be unable to afford your health care costs? 

Unfortunately, many people in Colorado and across the country have experienced this situation.  Even if you have health insurance, you may still be faced with high out-of-pocket costs such as co-pays, deductibles, or co-insurance.  Being “underinsured” is defined as spending 10% or more of your annual income on out-of-pocket medical expenses for people making at least 200% of the Federal Poverty Level ($23,340 for an individual and  $47,700 for a family of four).  Families and individuals who make less than 200% of FPL are considered underinsured when their out-of-pocket medical expenses exceed 5% of their annual income.  

The Colorado Health Access Survey found that 13.9% of Coloradans were underinsured in 2013, up from 12.8% in 2011.  People who are underinsured often have a limited number of covered doctor visits, annual dollar amount caps on how much their plan will cover, and are less likely to have dental benefits.  Additionally, when people cannot afford their co-pays or deductibles, they are often forced to forgo care that they need and their health suffers.  Underinsured individuals go without prescription medications, tests, and exams twice as often as do people with adequate insurance, according to a study done by The Commonwealth Fund. 

The Affordable Care Act includes reforms that are helping to improve insurance plans to reduce the number of underinsured.  In order for any plan to be sold on the health insurance exchange, it must be certified as a “Qualified Health Plan,” which means that they are required to cover ten essential health benefits including prescription drugs, maternity and newborn care, and hospitalization.  Previously, plans could exclude some services or procedures, meaning that you might have had to pay a lot out of pocket for health care services you need.  Now, most preventive services are provided free of any copay or additional charge to the consumer – removing the financial uncertainty of going to the doctor for many Coloradans.   

When shopping for coverage, consumers can determine what kind of out of pocket costs may be required for different plans.  Health insurance plans sold on state health insurance marketplaces, including Connect for Health Colorado, are organized into “metal tiers.”  The tiers are differentiated by what level of coverage they provide – platinum plans, which provide the highest level of coverage, require carriers to pay 90% of the cost of all medical services.  Bronze plans, on the other hand, cover 60% of the cost of care, leaving 40% to the consumer.  That means that the lower tiered plans have higher out of pocket costs so that someone who has health coverage may still find it difficult to pay their medical bills, leaving them underinsured.   Consumers who buy silver plans will be able to maximize their financial subsidies and have 70% of all medical costs covered by their insurer. 

Perhaps the most important protection the Affordable Care Act creates for underinsured Americans are maximums for consumers’ out-of-pocket spending. The Affordable Care Act ensures that an individual’s spending on medical costs cannot exceed $6,350, and a family’s maximum out-of-pocket cost limit is $12,700.  Consumers that have significant health care needs in a year no longer have to fear that their plans’ cost sharing structure could still leave them open to enormous costs. 

It’s not too much to ask to see your doctor and get the medical care you need without unpredictable costs.  The consumer protections in Obamacare have greatly reduced the possibility of being underinsured.  They help ensure that people who have health coverage can actually afford the medical care that they need with their insurance.  As implementation and improvements to the law continue, Coloradans may still need to work together to further ease the financial burden of the underinsured population so that all Coloradans are actually able to utilize health care services when they need to. 

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