© 2024 New Hampshire Public Radio

Persons with disabilities who need assistance accessing NHPR's FCC public files, please contact us at publicfile@nhpr.org.
Play Live Radio
Next Up:
0:00 0:00
Available On Air Stations
Purchase your tickets today and be entered to win $35k toward a new car or $25k in cash and so much more during NHPR's Summer Raffle!

What Makes A Health Plan Obamacare-Compliant?


We've been hearing a lot about health insurance policies that were canceled because they don't comply with the Affordable Health Care Act. That is, in some way, those policies don't meet the standards that the ACA set. And we were wondering in what way these policies typically fall short. And joining us to try to answer that question is Karen Pollitz, senior fellow at the Kaiser Family Foundation. Welcome to the program.


SIEGEL: And to the extent that we know, what would be a couple of the most common ways in which these noncompliant policies fall short of what's mandated by the ACA, Obamacare?

POLLITZ: Well, there are quite a few ways in which they wouldn't comply. One would have to do with the benefits that are covered or excluded. Particularly in the nongroup market, it is common for health insurance policies to not cover essential benefits such as maternity care, mental health services, prescription drugs, rehab after an accident.

Another way in which they might not comply is the level of cost sharing that is required for covered benefits. Usually, insurance won't pay the whole bill. You have to pay part, whether it's a copay or a deductible. And the cost sharing can be exceedingly high under many nongroup policies today. I've seen policies with annual deductibles of 7,500 or 10,000 or $15,000 for a person, and then additional cost sharing that applies after that, even after you've met the deductible.

SIEGEL: You mentioned maternity and newborn care benefits, which are mandated. We've heard from some people who say, look, my husband and I are in our late 50s. Our children are long grown and out of the house and off our policies. We're within, you know, a decade of qualifying for Medicare. Maternity care is just not something that we need. They can't buy a policy that excludes that benefit?

POLLITZ: Well, today, they will buy a policy that excludes the benefit. But in the future, no. All policies will have to cover it and...

SIEGEL: And what's the rationale for that?

POLLITZ: The rationale for that is when you're buying insurance, you and everybody else who's buying the policy are buying protection and you're sharing in that protection. So, you know, you don't have to buy a policy that covers maternity care, even though you're never going to have a baby. Maybe I don't want to buy a policy that's going to cover prostate cancer even though I'm never going to have that. So the policy takes care of people and all of the conditions that can happen to people, and we all kick in a premium so that there will be enough to take care of any one of our conditions when they arise.

SIEGEL: But - well, I know that you're reluctant to comment on this. When one looks at the set of 10 essential health benefits that any complying policy must have, not to mention the size of the deductibles and copays and treatment of pre-existing conditions, it seems, in retrospect, obvious that millions of policies that people might have had and might have thought they liked would not be there for them once the law became implemented and that the promise to everyone was a rash promise, at odds with the rules that were being written at that point.

POLLITZ: I think the promise had to do with the grandfather policies and had to do with the fact that most people today aren't in this market. They're in employer-sponsored coverage.

SIEGEL: In the group market.

POLLITZ: Right. And those people aren't going to have to do much of anything. They are going to stay in the policy they have. It's not going to have to change. The changes that are occurring are to make the nongroup market look and feel and cover more like what people are used to in the group market. So I think it will be a relatively small slice of the population that feels this change. But at the same time, I know that they are upset and confused about what's going on.

SIEGEL: Well, Karen Pollitz, thanks a lot for talking with us about noncompliant health insurance policies.

POLLITZ: Thank you.

SIEGEL: Karen Pollitz, who is a senior fellow at the Kaiser Family Foundation. Transcript provided by NPR, Copyright NPR.

You make NHPR possible.

NHPR is nonprofit and independent. We rely on readers like you to support the local, national, and international coverage on this website. Your support makes this news available to everyone.

Give today. A monthly donation of $5 makes a real difference.