Trendy-looking websites offer convenience and freedom from network pressures, for a fraction of the cost traditional health insurance.
“Welcome, insurance that’s finally fair” says one in bold letters. Another app says, “Take care your health with one simple app.”
This is all part of shopping to get health insurance in 2021.
These non-traditional products are still niche options. They say they aim to ease consumer frustrations with high premiums or deductibles.
One such offering, from insurer Sidecar Health, pays consumers its estimated cash price for each medical visit and lets them shop for the best deal. Another option, Antidote , is not insurance but provides access to online primary care for a small monthly charge.
These plans come with a dose “buyer beware .”
While the plan’s image portrays consumers taking control over their health care, the reality is the opposite, said Dania Palanker assistant research professor at Georgetown University’s Center on Health Insurance Reforms.
This is because they aren’t Affordable Care Act plans. These plans are not comprehensive and can leave patients responsible for thousands or hundreds of dollars. This could be due to the fact that they only cover a portion of a patient’s medical bills or other limitations.
The Sidecar Health and Antidote New York, both based in California, may be appealing to younger shoppers or those without subsidies to purchase Affordable Care Act plans.
Consumers feel ACA plans are too expensive or out-of-pocket expenses are too high, or they are not accepted by doctors, according to Mike Smith, president and CEO of The Brokerage in Texas, which recruits insurance agents, and also sells insurance .
These plans have lower premiums, partly because they cover less than ACA plans.
Standard Benefits do not cover maternity care. There is no annual limit on the amount patients can pay out of pocket. Some decline to enroll people who have health conditions that are not allowed under an ACA plan. Customers who use Sidecar may find that the amount they pay to cover care is less than what they actually pay. Antidote does not cover laboratory work, X-rays or costly drugs.
Sidecar’s Access Plan, licensed for sale in 17 states, adds a layer of pricing information to what’s known as fixed-indemnity plans. These plans pay a flat fee to the policyholder, which is usually a dollar amount based on what type of care they receive.
Unlike typical indemnity 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’s area for each service. This includes most services related to regular doctor visits, lab work, as well as line-item costs included in surgeon’s fees or hospital care.
However, the medical provider may not accept this amount as full payment.
Patients will be able to find out upfront from Sidecar how much it will pay towards a medical visit if they are clear about what they require. Then, they can shop around. Sidecar charges are paid by patients. If the patient is able to get it at a lower price than Sidecar’s rate then the enrollee will pay the difference.
CEO Patrick Quigley views his company as part a growing effort to harness price information. This may encourage reluctant Americans to compare shop.
” We’re creating a product that is transparent and controlled, turning patients into buyers,” he stated.
Some policy experts warn that the plan does not provide comprehensive coverage.
Indemnity insurance is useful for filling gaps in coverage, Palanker stated. However, “it’s not major medical insurance.”
Consumers must choose a coverage amount for the year, from as little as $5,000 to $2 million. If a person selects, say, $50,000 but faces a $100,000 hospital bill after a car accident or a bad case of covid-19, they are responsible for the difference.
Because they’re based partly on the total annual amount of coverage, premiums vary, but most are $200 to $300 a month, according to Sidecar.
Candidates must answer a series of health questions when applying, and those who weigh more than 300 pounds or have any of 13 specific health conditions are declined.
Quigley claims that the structure, which has no network or upfront price information, allows people to visit any doctor, hospital, or clinic they choose.
However, this means that all services are not available and that there is no guarantee that a provider or facility will take the Sidecar benchmark as payment.
“If the providers you need to see do not fall in line with the median amount paid in your area, you are on the hook,” said Joshua Brooker, a principal at PA Health Advocates, an independent brokerage that operates in 11 states. Sidecar is not sold by it.
For more complex procedures, such as surgery, Sidecar asks that members request a detailed estimate and all charges upfront. Then, they send it to Sidecar to calculate the cost.
“Consumers don’t know how to say, ‘I need all codes you are going to invoice,’” Stacey Pogue is a senior policy analyst at Every Texan. Every Texan is a policy research and policy group based in Austin. This product could be good for a sophisticated consumer who is knowledgeable about indemnity insurance, cash prices, and negotiating. But I don’t believe there are many of them .
In an emergency, there’s no way to shop around.
In these cases Sidecar states that it intervenes after the fact and negotiates directly to the hospital in order to get “a reasonable price,” Quigley stated.
Even proponents like Smith from The Brokerage said Sidecar might not be the right choice for everyone. He said that clients who decide to use it should be educated about its capabilities and limitations.
Consumers can purchase Sidecar’s Access Plan online through the company or participating brokers like Smith. It is not available through federal or state insurance marketplaces that offer ACA insurance.
This may change in Ohio.
Sidecar Health stated that it has been granted state approval to offer an ACA plan in the country, beginning in November and continuing through next year.
This version must comply with all law requirements, including the acceptance of applicants with preexisting medical conditions. It also imposes no dollar limits on the care it covers and caps enrollees’ out-of-pocket expenses. In some cases, its premiums may be higher than that of the Access Plan.
It will not have a network of hospitals and doctors like other ACA plans. With plan pricing information, consumers will be able to shop around.
Antidote, meanwhile, is sold in eight states. Monthly membership fees start at $35 for an individual or $59 for a family.
Ben Enosh, the co-founder of Antidote, initially referred to Antidote’s fees in terms of premiums. However, he later changed his mind and said that there is only one monthly fee. This is significantly less than insurance which requires a premium plus copays .”
It describes itself as a digital healthcare company, not an insurance company. They provide technical and administrative support for physicians. He explained that it is not licensed in many states it sells.
The plan is similar to “direct primary care” in that patients pay a monthly fee, which allows them to see their doctor who will then provide all their primary care. Antidote, unlike most other programs that require in-person visits, is entirely online. The patient may not be able to see the same doctor every single time and may even have to travel to another state.
Antidote has a network of 50 online doctors, some of whom are investors, Enosh said. Before an online visit, patients answer a health questionnaire, which takes about 10 minutes, he added. The algorithm analyzes the data and helps doctors determine what is going on. He said that the technology has reduced the average time taken to visit an online doctor by six minutes.
There are certain coverage limits.
Hospitalization and imaging tests are not covered.
Additionally, its “no extra fee” drug coverage includes only 80 types of medications, which may well take care of run-of-the-mill concerns but not cancer or other major conditions. These would be paid for by the patients.