When the Affordable Care Act’s health insurance marketplace opens in two weeks, many consumers will have a new option for the law’s fourth open-enrollment period: standardized health plans that cover basic services without a deductible.
With many health plans on the marketplace coming with deductibles in the thousands of dollars, consumers have complained that they were getting little benefit beyond coverage for catastrophic problems. The new standardized options are meant to address that concern — to ensure that “enrollees receive some upfront value for their premium dollars,” as the Obama administration said.
“Too many people, especially people on high-deductible plans, are still struggling to afford the care they need,” Senator Sherrod Brown, Democrat of Ohio, said, praising the new effort.
But the new plans could still be costly. While the federal government specifies deductibles, co-payments and other out-of-pocket costs for the standardized options, it does not limit premiums, which in most cases are still regulated by state insurance commissioners. The administration has said it does not expect the standardized options to have a significant effect on premiums in 2017.
Federal officials say the new option will simplify shopping under the Affordable Care Act by reducing variation among plans, and consumer advocates like the idea. The standardized options will be identified on HealthCare.gov with the label “Simple Choice.”
Open enrollment begins Nov. 1 and runs through Jan. 31. People without health insurance next year face possible tax penalties that could exceed $700 a person.
“This is one more tool that will make it easier for consumers to select the right plan,” said Marjorie K. Connolly, a spokeswoman for the Department of Health and Human Services.
Sandy H. Ahn, a researcher at the Health Policy Institute of Georgetown University, said the “standardized plans will allow consumers to make more of an apples-to-apples comparison.”
Administration officials did not say how many such plans will be available, in which states they will be offered or how much they will cost. The government encouraged but did not require insurers to offer standardized options.
The standardized version of a midlevel silver plan has a $3,500 deductible, but primary care and specialty care visits, outpatient mental health services and prescription drugs are generally exempt from the deductible. In other words, consumers may face co-payments, but they do not have to meet the deductible before the insurance company starts to pay for such services.
On HealthCare.gov, the administration intends to introduce the idea of standardized options by describing Simple Choice as “the easiest way to shop for plans.”
“All Simple Choice plans in the same category (like Silver) have exactly the same core benefits, deductibles and co-payments,” states a message to be displayed on the federal website. “When viewing Simple Choice plans, you can focus on other important features that may be different: monthly premiums, additional services covered, doctor and hospital networks.”
The Obama administration is still struggling to keep the Affordable Care Act affordable for many consumers. State officials have approved rate increases of 25 percent or more for many plans in 2017, after finding that insurers lost tens of millions of dollars in the exchanges. Aetna, UnitedHealth and other insurers have pulled back from the public marketplace, leaving consumers in many states with fewer choices.
Under the standardized version of a silver plan, co-payments would be $30 for a visit to a primary care doctor, $65 for a visit to a specialist, $15 for a generic prescription drug, $50 for a preferred brand-name drug and $100 for a nonpreferred brand-name drug. Consumers may be responsible for up to 40 percent of the cost of specialty drugs, including certain high-cost medicines for cancer, rheumatoid arthritis and multiple sclerosis.
For the lowest-income families, the charges would be lower.
Federal officials said they had studied several state-run exchanges — in California, Connecticut, Massachusetts, New York, Oregon and Vermont — that provide standardized options.
Peter V. Lee, the executive director of the California exchange, said standardized options had contributed to the stability and success of the marketplace there.
“Californians seeking coverage through the marketplace can easily compare health plans, knowing that every health plan has the same cost-sharing levels and benefits,” Mr. Lee said.
Insurers generally dislike efforts to standardize health plans. Standardized options “increase the complexity of the decision-making process” by adding one more factor for consumers to consider, said America’s Health Insurance Plans, a trade group.
In a letter this month to the Obama administration, Anthem, one of the nation’s largest insurers, said, “Standardized benefit designs threaten to commoditize insurance and stifle innovation, while potentially misleading consumers.” The administration said insurers still had discretion to vary many features that would not be standardized.