“Catastrophic” Health Insurance May Bring Old-Fashioned Style Medicine (DPC) Back!
The health insurance industry sucks. They are criminals in so many ways. They have done nothing but raise their premiums, raise patients’ deductibles, deny more and more orders from doctors, and the list goes on. I believe we all, doctors and patients alike, are on the same page with this.
And the premiums are going HIGHER in 2026!
Well, to combat this, CMS has decreed the following:
The Centers for Medicare & Medicaid Services (CMS) is working to expand access to catastrophic health coverage in the Federally-facilitated Exchange (FFE) through additional hardship exemption guidance, specifically designed to help consumers access coverage as a result of the premium increases anticipated for the 2026 plan year. This guidance describes circumstances that will support a hardship exemption for individuals who find themselves ineligible for advance payments of the premium tax credit (APTC) or cost-sharing reductions (CSRs) due to their projected annual household incomes, enabling access to more affordable, catastrophic coverage.
Catastrophic Plan Benefits
- Generally, consumers who are newly ineligible for APTC or CSRs due to their projected annual income (below 100 percent or above 400 percent of the federal poverty level (FPL)) will be eligible for a hardship exemption and can enroll in catastrophic coverage. CMS plans to begin streamlining this process for consumers ineligible for APTC due to income and expand to consumers who are over 250% of the FPL and are only ineligible for CSRs.
- This guidance applies to consumers in FFE States, and participating State-based Exchanges (SBEs) and will be made available to those seeking coverage off the Exchange.
- Catastrophic Plans: These plans provide all essential health benefits required under the Affordable Care Act while maintaining lower premiums designed for financial accessibility.
- Financial Protection: Comprehensive coverage is designed to provide financial protection against serious illness or injury that could result in devastating medical expenses.
- Preventive Care: Full access to preventive services without cost-sharing requirements. Catastrophic coverage may present an affordable coverage option for consumers who are ineligible for APTC or CSRs due to their projected annual household income, and may protect against worst-case scenarios, like getting seriously sick or injured.
There is a lot to like here. First, health insurance is NOT health care. Please know that. Health insurers are robber barons. They are not caregivers. That part needs to be removed from patients’ brains like they do in Men in Black.
This plan by CMS is brilliant….. maybe. If you are not below 100% or above 400% of the FPL (Federal Poverty Level), then you still have a safety net, though your deductible will still suck. For the rest of the population, here is a summary and my thoughts/questions:
- HOPEFULLY, the rates will be cheaper for a catastrophic plan. That’s the big question.
- You are financially protected if a major medical illness occurs. I need more info on that. What are the rates and how protected?
- Full access to preventative services. Uh oh. That seems great, but that just means more cost and could mean higher rates. They did this to make it more palatable, but they should have removed it. If people would shop around for medical services and pay cash, then it would bring the prices down.
All in all, this could be a great thing. That being said, I am not convinced that the government won’t screw this up like they do everything else.
The ONLY way this works is that if people choose this option, they also choose a Direct Primary Care doctor to help them navigate the system as well as give them great care. This is the opening we need to get DPC mainstream. Catastrophic insurance without a doctor or just using an urgent care is horrible.
If anyone has more information on this, please share it in the comments or email me at support at dpcnews.com.
Catastrophic health insurance is the entire point of DPC. It completes DPC. Big Insurance knows this, and is terrified of it. That’s why you can’t get it outside of an employer. And getting it through your employer makes no sense, since the employer is already subsidizing your insurance. We’re stuck in a circle instead of moving forward, and that’s exactly how UnitedHealth wants it.
Yes, read the CMS decree. You can get it.
Geez Louise, I heard about the catastrophic health insurance thing many, many years ago and thought it was a good idea
way back then though it was not implemented. Do DPC or a modest plan for office care (DPC would be more ideal if you ask me though) and have a plan to deal with hospital admissions!