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.
Cost-sharing in Exchange Policies
By Kevin RocheAugust 12, 2014Commentary
✅ Subscribe via Email
About this Blog
The Healthy Skeptic is a website about the health care system, and is written by Kevin Roche, who has many years of experience working in the health industry. Mr. Roche is available to assist health care companies through consulting arrangements through Roche Consulting, LLC and may be reached at [email protected].
Healthy Skeptic Podcast
This is an outstanding report on total global drug spending and trends, with projections out to 2025. It helps you understand this important area of health care, which does much...
June 1, 2021
MedPAC 2019 Report to Congress
June 18, 2019
Another example of over-priced companies trying to find some way to survive in the post-epidemic financial world. Transcarent, which does something, somehow to “access high quality, affordable care” is buying...
March 6, 2023
In an attempt to swiftly revive two floundering health care companies, a PE firm has announced the merger and recapitalization of Revive Health and SwiftMD. You know they are...
January 30, 2023
Investors have not yet learned their lesson, as Pearl Health gathers a new round of $75 million in capital for its business of supporting physicians who want to participate in...
January 30, 2023
Access ACO Care Management Chronic Disease Comparative Effectiveness Consumer Directed Health Consumers Devices Disease Management Drugs EHRs Elder Care End-of-Life Care FDA Financings Genomics Government Health Care Costs Health Care Quality Health Care Reform Health Insurance Health Insurance Exchange HIT HomeCare Hospital Hospital Readmissions Legislation M&A Malpractice Meaningful Use Medicaid Medical Care Medicare Medicare Advantage Mobile Pay For Performance Pharmaceutical Physicians Providers Regulation Repealing Reform Telehealth Telemedicine Wellness and Prevention Workplace
March 27, 2023
Why You Can’t Trust People Who Make Up Stuff About Vax Safety
A couple of studies offer a far better explanation for heart issues in athletes and…
March 25, 2023
Coronamonomania Lives Forever, Part 201
Tired of March Madness? A boringly refreshing dip into some CV-19 research summaries is recommended.
March 24, 2023
The CDC Is a Font of Methodological and Statistical Error
Several times in the last three years I and others have pointed out serious flaws…