Number Five: I’m Paying How Much?
The actuarial value of a Bronze level plan is 60/40. That gobbledy gook translates to your insurance company expects you to pay about 40% of the cost of covered services. That does NOT include your premium.
In reality, the numbers don’t work perfectly – but they are pretty close. So, for your Bronze level plan, expect to fork over about 40% of the overall cost of your health care – assuming you actually meet your deductible – and the annual cost of the premium you pay.
For the folks who don’t meet the deductible, the picture gets a bit murky. If your plan has built in copays (even limited ones) you still come out okay. If not, and nothing pays before deductible (which is very common) then you are paying 100% for covered services – and your premium too. Ouch.
Number Four: My Deductible Is Huge
Bronze level plans generally have very large deductibles. Now, for a healthy person that uses only the preventative services, that’s not a problem since you aren’t being asked to pay for anything (preventative services are covered at 100% in all four tiers). But your sprained ankle is going to hurt your pocketbook. Assuming no copays (every plan is different, but the least expensive are unlikely to have copays) and that the coinsurance is after deductible (also very common) then 100% of your ER visit and the follow up with your family doctor comes out of your pocket.
All of that goes toward the deductible – but few healthy people will reach a $6500 deductible in one year.
Number Three: Sneaky Copays
Some Bronze level plans will have copays. In rare instances, you can find Bronze plans with straight copays (meaning that covered services have a copay rather than coinsurances) – these are great for those who have minor medical needs throughout the year but don’t necessarily need more coverage.
More often, especially with physicians visits, you will find a limited number of copays. How that works is that the first two – three visits to your doctor for injury or illness you pay a set copay ($50 for example). But the visits after that are coinsurance after deductible – you pay 100% of the cost if your deductible hasn’t been met.
For a healthy person who isn’t likely to visit the doctor more than once or twice in a year this is a good option. But make very sure that you know what those limits are – some Marketplace sites can be confusing by showing both copay and coinsurance. If you aren’t sure, call and ask before you buy!
Number Two: After Deductible
This has already been mentioned but it deserves its own category. Two little words that can make a huge difference in what comes out of your pocketbook.
After deductible means what it says – the amount you pay before your deductible is met. In most cases with Bronze plans, you will be looking at a coinsurance that occurs after the deductible is met.
Let’s make it real: Your plan pays two $50 copays before the $6500 deductible for doctor office visits and a 75% coinsurance after deductible.
You go see Doctor Bob for your bunion and pay $50. You go again when you catch that virus going around and pay another $50. Then you twist your ankle – but this time you pay $200 because that’s Dr. Bob’s full price office visit rate and you haven’t met your deductible.
Since the coinsurance is AFTER deductible, and the deductible isn’t met, the coinsurance doesn’t do anything. So, when does it do something?
Back to our example: thus far you’ve paid $300 toward your $6500 dollar deductible. Unfortunately, you come down with a serious disease and have to be hospitalized. Your hospital bill comes out to $6200. You pay the whole $6200 – but now you have met your deductible,
Now, you go back to Dr. Bob for your follow-up. This time you pay $150. Why? Because a 75% coinsurance means you pay 75% of the actual cost. Since Dr. Bob charges $200 you pay 75% of $200.
Number One: Maximum Out of Pocket Costs
Each plan differs but maximum out of pocket costs aren’t usually proportionally very much more than the deductible. And maximum out of pocket means exactly what it says – it’s the maximum you will pay in a given year toward covered services.
So, back to our example. Your Maximum is $7150. You’ve met the deductible and now paid $150 beyond that – what happens next?
In an ill considered attempt to make extra cash to pay that deductible, you decide to try your hand at grizzly wrestling. It’s harder than it looks and the ER visit alone is charging $5000 – but you only pay $1000. When you follow up with Dr. Bob, you pay nothing at all.
Huh? This is the maximum out of pocket at work. You have now paid $7150 toward covered services – and you are no longer expected to pay anything toward covered services. Your insurance company now covers 100%.
This is really what Bronze plans are for – keeping you out of bankruptcy court when something goes really wrong.