By Jay Hancock, Kaiser Health News | article
As out-of-pocket medical costs grow for many Americans, the insurance industry is offering a way to help and, at the same time, expand its business: by selling supplemental policies that may fill the gaps for consumers.
The policies are promoted as helping cover out-of-pocket expenses that can reach thousands of dollars in plans offered by employers and the health-care law’s online marketplace.
“These supplemental health products have been recently — and we believe will be in the future — one of the fastest-growing components of the employer benefits market,” said Todd Katz, an executive vice president with MetLife.
Some experts, however, see risk for policyholders in the lightly regulated plans, which tend to be highly profitable for insurers and might be mistaken for more generous coverage.
“An individual has to understand this is something you buy to cover expenses that aren’t covered by a comprehensive medical plan,” said Timothy Jost, a law professor at Washington and Lee University and a consumer health specialist. “If employers are not offering it as [full] health insurance coverage, and if somebody gets sick and has some extra expenses, it might be okay.”
Federal regulators moved to ease restrictions on supplemental medical plans in January following industry lobbying while also noting “a significant increase” in such policies. The Labor Department signaled it would let plans pay benefits for each medical service, such as hospitalization or office visits. A previous rule, requiring payments per day or week, would have restricted consumer choice, the industry argued.
Not long ago, limited medical plans were thought to be doomed or severely restricted by the Affordable Care Act. According to figures from the Eastbridge Consulting Group, sales of supplemental hospital policies plunged in 2012 as the industry prepared for health-law rules requiring minimum coverage.
Instead of disappearing, the plans are rebounding, offered through employers or to individual consumers.
The health-care law requires most people to obtain and most employers to offer major medical coverage with certain essential benefits. Even so, what consumers pay out-of-pocket through these plans keeps rising as employers and insurers try to control their own costs.
“There’s been this demand in the market for a while” for supplemental coverage, said Todd Yates, a managing partner with Hill, Chesson & Woody, a North Carolina benefits consultant that expanded its supplemental-insurance sales team. “But it’s just continued to grow as employers offered leaner and leaner plans.”
For employer plans, the average deductible hit $1,135 last year, according to the Kaiser Family Foundation. Deductibles for silver and bronze plans, the most popular coverage sold to individuals through the health-care law’s online exchanges, averaged $2,567 and $4,343, respectively, in a study by Avalere Health.
A typical limited plan, also known as fixed-indemnity coverage, might cost $13 to $45 per month, depending on a customer’s age, and pay $10,000 or $20,000 upon diagnosis of a critical illness, according to Hill, Chesson. Other plans pay for hospitalization, cancer or accidents.
Fixed cash benefits are the common feature. Unlike with medigap, regulators have proposed banning supplemental insurance for those under 65 with payouts that are explicitly triggered by what’s left uncovered in another policy.
Even when employers offer the plans, workers generally pay the premiums through payroll deduction. Aflac is one of the biggest sellers of limited health plans.
Last year, MetLife started offering insurance that pays limited amounts for hospitalization, cancer or accidents, Katz said. Other sellers include Nationwide, Allstate and Aetna. In November, an affiliate of Highmark Blue Cross Blue Shield said it would start selling coverage that pays off for hospital admissions.
Consumer advocates want carriers to clearly disclose that limited plans are not minimum essential coverage under the ACA and won’t by themselves fulfill an individual’s requirement to be insured.
Neither will the policies automatically fill all out-of-pocket gaps in a high-deductible policy, analysts say. A limited cancer plan will not pay anything if you have a heart attack. A hospital plan will not cover out-of-pocket costs at a doctor’s office.
Others warn that fixed-indemnity plans might not be a good financial deal. Unlike major medical plans, which under the health-care law must spend 80 percent or 85 percent of their revenue on medical care, limited plans often spend 60 percent or less on claims, agents say. The rest goes for profits, overhead and broker commissions.
“I’m not a big believer in these things,” said John Jaggi, an insurance broker in Forsyth, Ill. For agents, he said, “the commissions can run anywhere from 30 to 45 percent in the first year. . . . And it’s possible to do that because you have such a high profit in these things and you don’t pay the claims out.”
To Thomas Rice, a health policy professor at University of California at Los Angeles, the surge in supplemental plans for those 65 and under sounds familiar. The early days of medigap plans for seniors in the 1970s were marked by lax regulation, expensive policies, a lack of standards and consumer confusion, he said.
Eventually, congressional hearings, new laws and industry reform improved medigap plans, he said.
No matter who the customer is, “a policy like this has a place if it returns the vast majority of premiums in terms of benefits,” he said. “If it’s keeping 40 percent of the premiums, it’s a disservice.”
Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.