Health Exchange Challenges

Have you or your loved ones encountered challenges trying to use health coverage purchased through a state health exchange? If so, you’re not alone.

This page outlines some of the challenges you or your loved ones may encounter as enrollees in a state exchange health plan, along with links to additional information and resources to help you resolve them.

High Cost Sharing

Cost sharing refers to the amount you or your family must pay out-of-pocket for prescription drugs or other services, such as seeing a specialist. Cost sharing usually comes in the form of a co-pay or co-insurance.

Under the average “silver” plan, some patients, particularly those with certain chronic conditions or serious illnesses, may have to pay as much as 50% out of pocket for the treatments they need.

Shifting the cost of medications to those patients most in need is not only unfair, but can also lead to families being unable to afford and access their life-saving medications. The Community for a Healthy Exchange wants health exchanges to work for all patients and the loved ones who care for them, including those dealing with serious or life-threatening conditions.

We believe the government should more carefully review formularies to ensure they do not discriminate against those with serious health needs.

Have you or a loved one encountered high out-of-pocket costs that affect access to needed health care? Share your story with us.

Narrow Networks

Many insurers in the health care exchanges today are turning to so-called “narrow networks” to generate cost savings, lower premiums, and attract more enrollees.

Narrow networks effectively ask for price cuts from health care providers in exchange for excluding some of their competitors from a health plan physician/provider network. This allows insurers to offer lower premium prices, but it also severely limits the options available to patients when choosing a primary care physician or a specialist.

Perhaps you did not realize that your or your loved one’s primary care provider and specialists were not included in the network of the plan you selected. We know that limiting access to providers can cause disruptions in patient care and even reduce the quality of care because a patient cannot access certain specialists.

The Community for a Healthy Exchange believes the health exchanges need to be more transparent and proactive in helping patients understand the limits of the networks associated with particular plans. They also need to ensure that patients have access to the medicines they need, even if those medicines have been prescribed by a doctor who is not in the patient’s approved network. We know that good network management (including narrow networks) is a key factor in keeping health costs low, but networks that are too narrow unfairly put certain providers out of reach for low- and middle-income beneficiaries and may put their health outcomes at risk as a result.

Have you or someone you care for experienced challenges accessing the most appropriate doctors to provide treatment? Share your experiences with us and let us know what you think can be done to fix the problem while still keeping health costs as low as possible.

Helpful links:  

Limited Formularies

The list of prescription drugs covered by a health insurance plan is called its formulary. Not all drugs are covered at the same level. Nearly all health plans organize their formularies in “tiers,” and different tiers have different co-pays, co-insurance, or limits on the amount or frequency with which a patient can access a particular prescription drug.

The way some exchange health plans have formulated their tiers, however, has made it difficult for patients and caregivers to afford or access some drugs, especially expensive treatments required to fight chronic conditions like multiple sclerosis, HIV/AIDS, and cancer.

This approach results in disproportionately high out-of-pocket costs for specific beneficiary groups, such as those with the chronic diseases mentioned above.

These maneuvers by insurers significantly undermine the intent of the health care reform law to protect you from unfair coverage practices while providing affordable care. We believe additional oversight of how drug formularies are developed is needed to protect our most vulnerable health care consumers.

Have you or someone you care for been unable to access the prescription medicines you need for a serious illness or chronic condition? Please share your experience with us and tell us how you think access can be made fairer.

Helpful links:  

Lack of Transparency

The insurance plans offered through the health care exchanges have a lot of variations, even within the same “metal” level (bronze, silver, gold, platinum). Everything from benefits and cost-sharing to what health care providers are included in a particular network and what kind of drugs are covered can all be different across plans and metal levels.

Did you find it difficult to decipher the specifics of each health plan option based on the information available on the health exchange websites? Many patients and their families have found the websites to be poorly designed, lacking detailed information, and offering few tools to help them determine what their actual out-of-pocket expenses will be.

We believe the most important change the exchanges can is providing easy-to-use tools that will help patients and their loved ones accurately calculate the real costs of each health plan given their particular health needs and circumstances.

There are several examples of changes that cold make a big difference for patients and caregivers:

  • Exchange websites could prompt patients and caregivers to choose the order plans are presented in, such as by price, “metal” tier, provider network, etc., rather than simply having the lowest-price plans appear first.
  • They could also provide clear information regarding how different types of products and services, like prescription medicines, count towards each plan’s deductible. Similarly, they could clearly highlight cost-sharing information for each formulary tier and other services in a particular plan so patients and caregivers can more accurately determine their likely out-of-pocket costs given the treatments and services they need.
  • Exchange websites could provide direct links to plan formularies so people can more easily see if their medicines are covered under a particular plan without having to click through multiple pages on the site or opening the plan’s cumbersome Summary of Benefits and Coverage documentation. (Health plans on the federal exchange are already required to do this by law, but not all state exchanges carry the same requirements.)

This kind of additional, user-friendly information would help ensure patients and caregivers really understand the health coverage they are purchasing and trust that it meets their needs.

Do you feel like you didn’t have enough information when you selected your health plan, or are you still struggling to understand what your insurance covers and what it doesn’t? Share your experience with us, and let us know what else you think could be done to make the health exchanges easier for patients and caregivers to understand.

Have you encountered other challenges in selecting or using your health exchange insurance plan? Share your experience with us here.