Affording Care: A Medical Student's Story
Published: Aug 24, 2013 | Updated: Aug 25, 2013, By Ben Hartman, MD, Contributing Writer, MedPage Today

The Affordable Care Act as approved by Congress required all insurance plans to limit personal out-of-pocket expenses to $6,350 for individual plans and $12,700 for family plans.

That requirement was set to kick in next year, but the Obama administration has sinceextended the time to implement that out-of-pocket cap until 2015. This delay will cover all "grandfathered" group plans: health plans for employees, students, professional groups, trade associations, and labor unions.

Three possible scenarios, from financial pain to financial ruin, may ensue as a result of this policy delay.

If a plan, which already has out-of-pocket maximums (OPMs) in place, uses a third party administrator (e.g., Express Scripts, Medco) for certain benefits, the insured may be responsible for an additional $6,350/$12,700 for those benefits (usually prescription drug and mental health coverage). This could lead to a doubling of annual out-of-pocket payments: $12,700 for individuals and $25,400 for families.

If a "grandfathered" plan uses third parties for both its mental health and prescription drug benefits, this could lead to a tripling of out-of-pocket costs for the policy holder.

If the third party administrator forgoes OPMs, the policyholder could pay unlimited copays for their medications and mental health services. Even worse, if the primary insurer (e.g., Aetna, United Healthcare) places an annual limit on its total benefit payouts, then the insured could be responsible for 100% of their medical costs after the provider reaches its annual limit.