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.
✅ Subscribe via Email
About this Blog
Healthy Skeptic Podcast
Research
MedPAC 2019 Report to Congress
June 18, 2019
Headlines
Tags
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
Related Posts
Commentary
Variation in Health Spending
February 16, 2025
Variation in Health Spending
Another interesting analysis of geographic variation in health spending.
Commentary
All Quiet on the Western Front
February 15, 2025
All Quiet on the Western Front
The pre-eminent description of war's impact on those who must fight it was written after…
Commentary
Yesterday’s 30-year US Bond Auction Did Not Go Well
February 14, 2025
Yesterday’s 30-year US Bond Auction Did Not Go Well
Warning signs aplenty if Congress does not get its act together on deficit reduction.