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Out-of-pocket caps will be higher for some under ACA delay

Certain plans that use different administrators for medical and drug benefits now have until 2015 to establish a unified limit on annual out-of-pocket expenses.

By David Glendinning — Posted Aug. 23, 2013

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In a change brought to light only recently, the Obama administration in February quietly delayed for some health plans an Affordable Care Act requirement establishing maximum amounts that enrollees would be expected to pay for care in a given year, raising concerns that some patients might forgo needed services as a result.

The ACA authorized a unified annual out-of-pocket cap of $6,350 for individuals and $12,700 for families to start in 2014. But because some health insurers use separate pharmacy benefit managers to administer the drug benefit portions of their plans, the administration acknowledged that these plans’ systems in many cases would not be able to communicate with each other to keep track of the total amount a beneficiary had spent in a given year.

An extension granted to these plans delays the unified cap until 2015. For affected plans, patients might face separate caps for their drug spending and their spending on medical care, effectively doubling the $6,350 and $12,700 maximums established by the ACA. If the separately administered drug plans do not impose an out-of-pocket limit now, they will not be required to do so in 2014.

Concerns of missed care

The delay, first reported in The New York Times, prompted worries from patient advocacy groups that patients will avoid receiving necessary care if they are still thousands of dollars away from hitting the catastrophic limit. The cap had been cited by several organizations as one of the key reasons for their support of the ACA’s enactment, especially those representing cancer patients and others who face relatively high prescription drug costs.

The delay also gave more ammunition to GOP critics of the law, including Sen. John Barrasso, MD (R, Wyo.), who said it will negatively affect patient access to affordable care.

“The reason this law keeps getting delayed is because it doesn’t work like the president promised it would work,” Dr. Barrasso said in a statement. “Instead of capping patient costs, the administration simply changed the rules. Instead of making the health care system easier to use, the administration made it even more confusing and uncertain.”

But White House Principal Deputy Press Secretary Josh Earnest, speaking to reporters on Aug. 14, noted that congressional Republicans are pushing to repeal the ACA, a move that would eliminate all mandated caps and leave patients exposed to potentially unlimited out-of-pocket costs. He said that the delay applies only to the class of employer-based plan that uses separate plan administrators — and that enrollees in those plans would be able to switch to plans offered through ACA health insurance exchanges if they didn’t want to wait until the unified cap kicks in for all plans starting in 2015.

“So when I say that every single American will have access on schedule and on time on Jan. 1 to a health care plan that limits out-of-pocket medical costs, that is a promise that the president has made good on, and that is a promise that we are pleased about,” Earnest said.

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