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Cost-sharing in Exchange Policies

By August 12, 2014Commentary

The biggest surprise to many of the new public health insurance exchange enrollees may not be the premiums, it likely will be the copayments and deductibles applicable to the services they seek.  A brief put together by Breakaway Policy Strategies and funded by the Robert Wood Johnson Foundation examines the cost sharing amounts for primary care and specialty physician visits in every silver level plan in every state for the 2014 filings.   (RWJ Brief)   So here is the great news for consumers–it can cost a lot.  Across the country copayments from primary care visits ranged from zero to $75, with a median of $35 and when coinsurance was used it ranged from zero to fifty percent, with a median of 25%.  (Note that we need to know what enrollment was under each plan to know how much consumers are really paying; that is to calculate a true paid median and paid average.  I suspect the actual paid is higher than these medians because consumers were more likely to enroll in less expensive silver plans, which likely had higher cost-sharing.) About 68% of plans used copayments and 23% used coinsurance for primary care visits.  For specialist visits, copayments were $10 to $150, with a median of $75 and coinsurance amounts went from 8% to 100%, with a median of 40%.  About 60% of silver plans charge copays for specialist care and 25% use coinsurance.  In addition, a significant number of exchange plans subjected physician visits to the deductible, which is rare in employer-sponsored coverage.  A few individuals may be eligible for cost-sharing reduction subsidies which mitigate the pain.  And a very small number of plans have no copay for visits to primary care doctors, but typically only for the first five visits a year.  There are some other interesting coinsurance/copay/deductible combinations and waivers in a few plans.  Seeing out-of-network providers is even more expensive and the cost-sharing amounts for these providers do not count toward the out-of-pocket maximum.  And some plans don’t cover out-of-network services at all, meaning the patients pays the full cost.  Coupled with the narrow network design needed for the plan sponsors to get premiums to any kind of a reasonable level, and consumers are going to feel very squeezed.  All of these factors show why tools and other resources are needed to help consumers make good decisions that minimize their likely financial exposure for health care services.  Welcome to the wonderful brave new world of health care reform.

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