Jay Ackroyd at Eschaton is looking at an insurance grid and is trying to analyze costs for people buying a Bronze plan in New York State. He is making a serious error in what he is analyzing. Benefit grids are not legally binding documents; they are short hand to describe the rough characteristics of a plan. If one wants to be able to analyze possible cost-sharing responsibilities, you have to use the schedule of benefits for a particular plan. Cost sharing is an insurance industry term for payments of deductibles, co-pays and co-insurance by the individual member.
This is always important, but it is more important in a PPACA world because numerous common services are considered “non-cost share” services. This means the insurance company pays 100% of the service’s contract price if the service is performed in-network. Secondary items that result from a non-cost shared service such as lab work from the annual PCP visit may be cost-shared which means the doctor’s visit is free but the blood work is something that you have to spend deductible dollars on is common. If the blood work comes back with a problem that needs to be treated, the follow-up treatment is cost shared.
PPACA mandates non-cost shared services for annual PCP and OBGYN appointments, well-child visits, preventative vaccinations, birth control and a few other things. Additionally three sick primary care provider visits are limited cost-sharing services in that a co-pay can be charged but deductible does not have to be met. So the first three sick PCP visits may have a $40 co-pay per visti but no additional cost while the 4th sick PCP visit may cost $107 that is applied to the deductible.
Non cost-shared services and cost shared servicesPost + Comments (37)