As the number of people covered by high-deductible health plans soars,聽some insurers and employers are easing the strain on consumers鈥� wallets by covering certain benefits like doctor visits or generic drugs before people have reached their plan鈥檚 deductible. But聽there鈥檚 a hitch: Under Internal Revenue Service rules, high-deductible plans that are set up to聽link to health savings accounts聽can only cover聽preventive services like vaccines and mammograms聽until patients聽buy enough services on their own to pay down their聽deductible.
A 聽was introduced in Congress in July that would allow聽high-deductible plans聽that can link to health savings accounts (HSA) to cover care for chronic conditions like diabetes and heart disease before plan members have met their deductibles.
Health savings accounts were introduced in 2004, reflecting the popular belief that if consumers had more financial 鈥渟kin in the game鈥� they would make smarter, more cost-effective decisions. Individuals and their employers can deposit money into the accounts tax free, where it grows tax free and can be withdrawn tax free to use for medical expenses. The accounts must be linked to health plans that meet certain federal standards, including minimum deductibles of $1,300 for individuals and $2,600 for families in 2016. The plans are required to cover preventive services聽without cost sharing, but consumers must pay for all other services聽until they meet their deductible.
Many high-deductible plans don鈥檛 meet those standards. The HSA-plan deductible coverage restrictions can be a sticking point when employers and insurers consider what plans to offer.
鈥淚鈥檝e worked with numerous clients that chose not to pursue an HSA strategy because they wanted their employees to be able to get coverage not subject to the deductible,鈥� said Jay Savan, a partner at Mercer Health and Benefits, a consulting firm.
This legislation would lift those restrictions to some degree, but its passage聽is far from assured, say experts.
It could make a big difference to Cheri Amos-Prater. Diagnosed with rheumatoid arthritis and psoriasis 10 years ago, the 54-year-old drug sales representative had been paying approximately $50 in monthly copayments to her聽health plan for Humira, a drug sold by her company, AbbVie. This year, she switched to a high-deductible plan with a health savings account, not realizing that she would be responsible for paying the first $3,000 of her medical care to satisfy her deductible before her plan鈥檚 coverage kicked in. Her Humira alone would have cost聽$2,100 in January. Unable to afford it, she stopped taking the drug.
鈥淚 didn鈥檛 realize that in the fine print of the policy it said that if I made this choice I couldn鈥檛 get the drug at a discount鈥� until meeting the deductible, said Amos-Prater of Birmingham, Alabama. She plans to go back to a regular PPO plan next year.
The legislation has been endorsed by consumer groups and policymakers who are proponents of 鈥�,鈥� which encourages health-plan features that nudge consumers to get聽clinically effective care聽by reducing or eliminating out-of-pocket costs for such services.
鈥淲e need to spend money differently,鈥� said Dr. A. Mark Fendrick, director of the University of Michigan Center for Value-Based Insurance Design. 鈥淲e should put a very high deductible on those things we don鈥檛 need and incentivize consumers to get the care they need.鈥�
For example, he pointed to to prevent adult-onset blindness,聽鈥測et the fastest growing type of health plan, HSA high-deductible plans, covers those exams not at all,鈥� he said.
Twenty-nine percent of workers with employer-sponsored coverage are enrolled in a high-deductible plan with a savings account of some sort, according to the Kaiser Family Foundation鈥檚 , up from 17 percent in 2011.聽(Kaiser Health News is an editorially independent program of the foundation.)
These enrollees also聽generally pay more out of pocket for care than people in traditional plans. People in high-deductible plans were responsible for 24 percent of their medical costs between 2010 and 2014, on average, compared to 14 percent for people in traditional plans, according to a recent that examined claims data from three major insurers for 40 million Americans.聽Annual per capita spending out of pocket was $1,030 on average for those in high-deductible plans compared with $687 for people in traditional plans.
Both employer-sponsored and marketplace plans often cover services before the deductible in聽plans. Two-thirds of plans on the federal marketplace exclude primary care visits from the deductible, according to .聽Similarly, the deductible doesn鈥檛 apply to a majority of workers in when they visit their primary care doctor.
Insurers that want to attract people, especially healthy people, realize that offering a plan with hardly any coverage before a huge deductible may not do the trick, said Caroline Pearson, senior vice president at Avalere Health, a research and consulting firm.
Still, it鈥檚 unclear that insurers would jump at the chance to offer plans that are particularly attractive to people with chronic illnesses, said Linda Blumberg, a senior fellow at the Urban Institute鈥檚 Health Policy Institute.
America鈥檚 Health Insurance Plans, a trade group, has endorsed the proposed legislation, because it would give insurers more flexibility to design plans that ensure that consumers get the right treatment at the right time, said AHIP spokesperson Clare Krusing.
Even if there is the political muscle to pass the bill, it could be difficult to design plans that provide pre-deductible coverage for chronic conditions without pushing premiums up, said Pearson.
Advocates of value-based design 鈥渨ould say that if you鈥檙e covering the right services, it shouldn鈥檛 increase costs,鈥� she said. But how do you discourage coverage of the ineffective physician visits while encouraging coverage of the effective ones? 鈥淲e are not yet particularly skilled about designing services that are nuanced,鈥� Pearson said.
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