Health insurance premiums may not be the only thing going up in 2015 under the Affordable Care Act.
Out-of-pocket expenses are increasing under some plans available to Chicago-area consumers, a Chicago Sun-Times analysis of federal government data found.
Twenty percent of the 125 insurance plans available in Cook, DuPage, Kane, McHenry and Will counties have higher out-of-pocket maximums in 2015 than in 2014. None of the plans decreased their maximum out-of-pocket limit.
A health plan’s out-of pocket maximum is how much a consumer might have to pay for covered health care during the year excluding premiums.
Fourteen plans available in the six-county area will see an increase in medical deductibles required in 2015 — the dollar amount that must be reached before the insurance plan kicks in. Some deductibles increased by as much as $500.
And several plans had different language regarding coverage for primary care doctor visits or for specialty drugs, which could result in more expenses, the Sun-Times found.
People who bought a plan last year will be automatically enrolled in the same plan for 2015 or a comparable plan if that 2014 insurance plan no longer exists, if they take no action, the federal government has said.
Consumers who don’t take the time to read the fine print might not realize there are differences.
For example, take Blue Cross Blue Shield of Illinois’ Blue PPO Bronze 005 for a 40-year-old in Cook County. While parts of the plan — such as the medical deductible amount and charge for specialty drugs — didn’t change, the maximum amount a consumer is responsible for paying on top of their premium will increase from $6,250 in 2014 to $6,600 in 2015.
Similarly, Coventry Bronze $20 Copay Select in Cook County will see the premium decrease in 2015. But the maximum medical out-of-pocket increased from $6,350 to $6,600. Plus, the emergency room cost goes from a $500 co-pay before the deductible is reached to $250 co-pay after deductible. That change means the insurer, Coventry Health Care, would no longer be required to pay for any portion of an emergency room visit until consumers meet their deductible.
A spokeswoman for Health Care Service Corp., which operates Blue Cross in Illinois, said that costs and premiums are based on several different factors.
“While some bronze plan deductibles may be higher than others, other cost-sharing factors, like co-insurance or doctor visits, will likely be lower within those plans,” Lauren Perlstein said.
Coventry, meanwhile, said the changes made in Bronze $20 Copay were, in general, about being competitive and finding the balance between affordability and value.
“We believe our products are competitive with the products offered by other carriers in the marketplace,” said Cynthia Michener, a spokeswoman for Aetna Inc., which acquired Coventry.
The Sun-Times looked at the fine print only for insurance plans that existed in 2014 and would again be offered in 2015. Among the factors looked at for individuals and families were: medical deductible; co-payments for visits to a primary care doctor; cost for emergency room visits; and expenses for generic drugs and specialty drugs.
Consumers may qualify for additional help to lower their out-of-pocket costs depending on their income and the plan they are enrolled in.
Not all changes were bad for consumers. Some plans decreased the amount required to pay for a specialist or a primary care doctor.
Blue PPO Silver 004, for instance, won’t see a change in maximum out-of-pocket, medical deductible or many other areas. And the plan will also see a decrease of charges for going to a primary care physician and specialists.
Most plans did not see a change in drug deductibles, co-payments for primary care physicians or emergency room.
The Affordable Care Act puts some restrictions on how insurers can change a plan, based on whether it is bronze, silver, gold or platinum.
Bronze plans, for example, must cover about 60 percent of a person’s overall health services, while a gold plan must cover 80 percent. To meet that requirement, insurers would need to charge less for something if they wanted to increase a charge somewhere else.
State officials, along with many health experts, have urged consumers who bought plans last year to examine their options in 2015 — even though they would be automatically enrolled in the same plan if they did nothing.
Criticism of the auto-enrollment practice has led the federal government to reconsider the practice for 2017.