When the ACA was enacted, leaders of community health centers were excited about the prospect of their previously uninsured patients getting coverage and having their levels of uncompensated care drop. But they were surprised when many of their lower-income patients bought bronze plans with high cost-sharing and started coming in seeking treatment on a sliding-scale fee basis. Previously, sliding-scale fees were used mostly by uninsured people who had to pay their own bills.
The centers say this has had a negative impact of their finances. “The use of the sliding fee scale due to the inability to pay required co-pays impacts the community health centers’ uncompensated-care costs, which are not declining as rapidly as contemplated by some policymakers,” said Mary Leath, CEO of Community Health Centers of Arkansas.
The squeeze is being felt even in states that have expanded Medicaid to adults with incomes up to 138% of poverty, which has provided community health centers in those states with more paying patients. Deb Polun, director of government affairs at the Community Health Center Association of Connecticut, said the lowest deductibles for bronze plans in her state are about $4,000, which is not affordable for lower-income patients.
This is an interesting development that points to some potential implications:
1. Lower income households are mistakenly choosing high deductible bronze metal tier plans that are ill suited to their economic resources and health statuses — particularly among people who are frequent users of primary care services — because they don’t understand how out of pocket cost sharing works and believe health plans are all inclusive.
2. These households should be but are not being directed toward silver metal tier plans that feature cost sharing subsidies for households earning up to 250 percent of federal poverty. If so, this suggests state health benefit exchanges and those who help people choose individual plans such as insurance agents need to do a better job ensuring consumers are getting adequate information in order to choose the best metal tier plan for their circumstances.
3. Lower income households are deliberately selecting bronze plans in order to benefit from their lower premiums, knowing they can get low cost primary care on a sliding scale fee basis from community health centers.
4. Lower income households are overestimating their incomes and should be enrolled in Medicaid programs if eligible instead of exchange plans. California’s state-operated exchange, Covered California, has switched some plan year 2014 enrollees from exchange plans to Medicaid when income redeterminations for plan year 2015 found some households earning too little to qualify for an exchange plan.
The item reports bronze health plan issuers are denying claims submitted by CHCs, which are then written off as uncompensated care. This raises the question of the type of care for which reimbursement is requested since preventative services are not subject to cost sharing and are included in plans at all metal tiers of coverage.
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