Health plans

New health plans offer twists and turns on existing options, with a dose of ‘watch out for buyers’

Non-traditional plans offer lower premiums, in part because the plans cover less than ACA plans.

This article was published on Thursday, November 4, 2021 in Kaiser Health News.

By Julie Appleby

Trendy websites promise convenience and the absence of networks, at a cost well below the cost of traditional health insurance.

“Welcome to insurance that’s finally fair,” says one, in bold print. “Take care of your health with just one easy application,” says another.

It’s all part of buying health coverage in 2021.

While still niche products, these non-traditional options aim to assuage consumer frustration with high premiums and deductibles by exploiting the growing availability of pricing information or the new patient comfort with online health services.

One such offer, from insurer Sidecar Health, pays consumers its estimated cash price for each medical visit and allows them to seek out the best deal. Another, from Antidote Health, is not insurance, but offers access to online primary care only for a small monthly fee.

Yet these plans come with a dose of “buyer’s beware”.

While the picture the plans present is of consumers taking control of their health care costs, the “reality is probably the opposite,” said Dania Palanker, assistant research professor at the University’s Center on Health Insurance Reforms. of Georgetown.

This is because they are not Affordable Care Act plans. This is not comprehensive medical insurance and patients could be held liable for hundreds or even thousands of dollars, either because the benefits only cover part of a medical bill or because of other limitations of the plan.

What’s on offer by New York-based California-based Sidecar Health and Antidote may appeal to younger or more tech-savvy buyers, uninsured people, or those who do not receive grants to help them purchase plans of. the Affordable Care Act.

Consumers say ACA plans are “too expensive, or the out-of-pocket costs are too high,” or doctors don’t accept them, said Mike Smith, president of The Brokerage, a Texas-based marketing organization that recruits insurance agents and sells insurance.

But the lower premiums of these plans are possible, in part, because the plans cover less than the ACA plans.

Standard benefits do not include maternity care, there is no annual limit on how much patients can pay out of pocket, and some refuse to enroll people with medical conditions. is not allowed in an ACA plan. Sidecar customers may find that the amounts they receive to pay for care are lower than they are charged, while Antidote does not cover lab work, x-rays, hospital care, or expensive drugs.

Sidecar’s access plan, cleared for sale in 17 states, adds a layer of pricing information to what’s known as flat-rate plans. These plans pay the policyholder a flat rate, usually a dollar amount, depending on the type of care they receive, such as a visit to the doctor or a day in the hospital.

Unlike typical compensation plans, Sidecar provides more information, including individual payment calculations for 170,000 services based on its estimates of the average cash price in the patient area for each service. This encompasses most of the services associated with regular doctor visits and lab work, as well as individual costs included in the surgeon’s fees and hospital care.

But the health care provider may not accept this amount as full payment.

Patients can learn in advance from Sidecar how much it will pay for a doctor’s visit – if they know what they need – then shop around. Patients pay any difference between the Sidecar allowance and the actual price. Conversely, if the patient can obtain it for a price lower than the Sidecar rate, the registrant pockets the difference.

CEO Patrick Quigley sees his company as part of an emerging effort to exploit the growing availability of price information, which may cause reluctant Americans to shop around.

“We are building a product around transparency and control, turning patients into buyers,” he said.

Some policy experts warn that the plan falls short of full coverage.

Indemnity insurance can be useful in filling gaps in coverage, but “it’s not major health insurance,” Palanker said.

Consumers should choose an amount of coverage for the year, from as little as $ 5,000 to $ 2 million. If a person chooses, say, $ 50,000 but faces a $ 100,000 hospital bill after a car accident or severe case of COVID-19, they are responsible for the difference.

Because they’re based in part on the total annual amount of coverage, premiums vary, but most range from $ 200 to $ 300 per month, according to Sidecar.

Applicants must answer a series of health questions when applying, and those who weigh over 300 pounds or have one of 13 specific health concerns are turned down.

Quigley says the structure – no network, advance pricing information – allows people to go to any doctor, hospital or clinic.

But it also means that all services are off-grid and there is no guarantee that a supplier or establishment will accept the Sidecar benchmark price as full payment.

“If the providers you need to see don’t match the median amount paid in your area, you’re hooked,” said Joshua Brooker, director of PA Health Advocates, an independent brokerage that operates in 11 states. He does not sell a Sidecar.

For complex treatments, like surgery, Sidecar asks members to request a detailed quote in advance with all expected charges, then send it to Sidecar for a calculation of what it would pay.

“Consumers aren’t used to saying, ‘I need every code you’re going to charge,” said Stacey Pogue, senior policy analyst at Every Texan, a research and policy group in Austin. “For a really smart consumer who understands indemnity insurance and spot prices and negotiation, this might be a good product, but I just don’t think there are that many such consumers.”

There is also no way to shop in an emergency.

In these cases, Sidecar says, he steps in after the fact and negotiates directly with the hospital, aiming for “a reasonable rate,” Quigley said.

Even supporters, including The Brokerage’s Smith, said Sidecar may not be the best choice for everyone. Customers who choose it should educate themselves on how it works, especially its limitations, he said.

Consumers buy Sidecar’s access plan online from the company or through participating brokers like Smith, and not through federal or state marketplaces that offer ACA insurance, as it is not about major medical coverage.

That could change soon, at least in Ohio.

Sidecar Health said it has state approval to sell an ACA plan there, starting in November for coverage next year.

Because this version must meet all the requirements of the law – including accepting applicants with pre-existing medical conditions, imposing no limits on the amount of care it will cover, and capping reimbursable costs. of registrants – its premiums may in some cases be higher than the Access plans.

Unlike the ACA offerings of other operators, it will not have a defined network of doctors and hospitals. Consumers will shop around armed with information on the plan’s pricing.

Antidote, meanwhile, is sold in eight states. Monthly membership fees start at $ 35 for an individual or $ 59 for a family.

Co-founder Ben Enosh initially described Antidote’s fees as premiums, but later corrected himself to say that the program had “a monthly subscription at a significantly lower price than insurance, which requires a premium plus deductibles and a quota “.

And it describes itself as a “digital healthcare company”, not insurance, providing technical and administrative support to physicians. This is why, he said, it is not licensed by insurance regulators in several states where it is sold.

The plan is like “direct primary care,” where patients pay a monthly fee to their local doctor, who then provides all of their primary care. Unlike most of these programs, which include in-person office visits, Antidote is completely online, the patient may not see the same doctor every time, and the doctor may well be in a different state.

Antidote has a network of 50 online doctors, some of whom are investors, Enosh said. Before an online visit, patients take a health questionnaire, which takes around 10 minutes, he added. Analyzed by an algorithm, this data then helps doctors decide what might happen. The technology has reduced online visitation time to an average of six minutes, he said.

There are defined coverage limits.

The Antidote service only offers primary care visits, although Enosh said it informs registrants of cash prizes available at nearby labs. The terms of use for the online plan show that doctor visits are limited to 12 per year for individuals and 20 for families, after which a fee of $ 15 per visit applies.

Hospitalization, imaging tests and surgery are not covered.

In addition, its “no additional cost” drug coverage includes only 80 types of drugs, which may well treat common problems, but not cancer or other major ailments. Patients should pay for them themselves.

Julie Appleby:, @Julie_Appleby

Kaiser Health News is a national health policy news service that is part of the non-partisan Henry J. Kaiser Family Foundation.