If Merriam-Webster had anything to do with it, the concept of a deductible would be simple — the "amount of money that you have to pay for something (such as having your car fixed after an accident) before an insurance company pays for the remainder of the cost".
With Washington state health insurers though, it turns out things are a lot more complicated. This past year, while making a difficult recovery from knee surgery, I've been encountering these complexities. Here's how the system works:
1) Deductible Double-Standards
Even though the marketing materials for healthcare plans traditionally promote one deductible, there are often actually two deductibles. This year I opted into Lifewise’s $1,000 deductible Gold plan. Here’s the thing though: That $1,000 deductible only applies when I visit medical professionals in the Lifewise network.
When I visit professionals outside the network, even if they are licensed by the State of Washington, I have a fully separate $2,000 deductible. Therefore, my $1,000 deductible plan actually has $3,000 of deductibles. Some plans are worse: The Bridgespan $1,000 deductible plan has $6,000 in combined deductibles. By design, HMOs such as Group Health and Ambetter provide no coverage at all for out-of-network providers; their out-of-network deductible is infinity.
Side note: Even Lifewise itself can't keep track of which doctors are in- or out-of- its network. Though their Explanation of Benefits (EoB) says that the UW Medical Center is in-network, when I visited a doctor there, my payment was applied to my out-of-network deductible. A follow-up phone call revealed that the UW Medical Center is, actually, out-of-network.
One downside of the Affordable Care Act (ACA) is that insurers are now even more restrictive of who they allow into their networks. A handful of providers have told me that insurers purposely limit entry to their network in order to reduce expenses. Seattle's Children's Hospital is even suing the state Office of the Insurance Commisioner because only two of seven plans on the state exchange include it in their network.
When it comes to auto insurance, Washington state law requires insurers allow you to repair your car at the vehicle repair shop of your choice. There's no such freedom with health insurance.
2) Limits on the Number of Visits that Override Your Deductible
Amazingly, even once you’ve met your deductible, insurers can completely set aside your coverage if you exceed visit limits in certain categories of treatment. For example, my current plan provides no coverage for physical therapy after 25 visits — even if my in-network deductible is satisfied.
In other words, if you're hit by an uninsured driver, you get 25 visits of physical therapy and then nothing until you’ve hit the new ACA out-of-pocket limit of $6,350. For those keeping track, that’s $5,350 you’ll have to pay yourself — in addition to the $1,000 deductible you already paid. And, as I'll describe below, many costs you would incur wouldn't count towards the limit, they'll be paid completely out-of-pocket.
Washington state's interpretation of the ACA set a minimum number of physical therapy appointments insurers are required to provide (which actually increased my insurer's visit limit by five). Still, the free marketplace hasn't yet unearthed any insurers that offer a more competitive plan without visit limits. (Don't worry, I'm sure Libertarians are right about other things.)
3) Copays Don't Count Towards Your Deductible
Most Washington insurers require a copay for some provider visits as well as prescription drugs. For example, my plan often requires a $30 per visit copay — 25 percent of a typical $120 medical visit. Copays don't count towards your deductible at all. Don't ask me to explain which visits require copays and how much they are. No matter who I ask, it remains one of life's little mysteries.
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