Analyzing Subsidies and Cost-Sharing Under the ACA

Subsidies under the Patient Protection and Affordable Care Act (ACA) have been under the microscope for some time since the first year of open enrollment on the healthcare exchange began in late 2013. As the second year of marketplace enrollment came to a close, a report from the Kaiser Family Foundation examined subsidies and cost-sharing under the ACA.

Related Content:

Supreme Court Decision on ACA Subsidies Has Patients and Providers Concerned

CBO Says Healthcare Insurance Subsidies to Cost Less Over the Years

Specifically, the researchers analyzed silver plan options on the exchange, as the ACA provided reduced cost-sharing if enrollees selected a plan from the silver tier in the federal or state marketplace. According to the report, standard silver plans are expected to have an actuarial value of 70%. More specifically, individuals with incomes ≤150% of the federal poverty level (FPL) can enroll in a plan where the actuarial value is increased to 94%, while people with incomes between 150% and 200% of the FPL can enroll in a plan where the actuarial value is increased to 87% and people with incomes between 200% and 250% of the FPL can enroll in a plan where the actuarial value is increased to 73%. In the analysis, these variants are referred to as CSR94, CSR87, and CSR73 plans, respectively.

The results indicated that 55% of all silver plans combined medical and prescription drug deductibles. The average medical deductible in plans with combined coverage was $2077 in the CSR73 plan, $737 in CSR87, and $229 in CSR94. The average medical deductible in plans that did not combine coverage was $2763 in the CSR73 plan, $659 in CSR87, and $159 in CSR94. The average prescription drug deductible in plans that did not combine coverage was $224 in the CSR73 plan, $79 in CSR87, and $37 in CSR94. Overall, the average out-of-pocket limit for plans with combined medical and prescription drug deductibles was $4624 for the CSR73 plan, $1692 for CSR87, and $881 for CSR94.

The average inpatient facility coinsurance rate was 27% for the CSR73 plans, 19% for CSR87, and 16% for CSR94. In terms of inpatient physician services, the average copayment for CSR73 plans was $176 and the average coinsurance rate was 27%. For CSR87 plans, an average $133 copayment and a 19% average coinsurance rate were estimated compared with $125 and 16%, respectively, for the CSR94 plans.

For the 3 plans (CSR73, CSR87, and CSR94), the average copayment for a primary care physician was $23, $17, and $14, respectively, while the average coinsurance rate was 25%, 24%, and 22%, respectively. For the 3 plans, the average copayment for a specialty provider was $51, $35, and $25, respectively, while the average coinsurance rate was 26%, 24%, and 21%, respectively. For the 3 plans, the average copayment for an emergency department visit was $270, $196, and $168, respectively, while the average coinsurance rate was 27%, 21%, and 19%, respectively.

The report also examined a variety of drug costs throughout the silver plan options. The average copayment for generic medications was $11 for the CSR73 plan, while the average coinsurance rate was 28%. For the CSR87 plan, the average copayment for generics was $8, with a 26% coinsurance rate. And, for the CSR94 plan, the average copayment for generics was $7, with an average coinsurance rate of 23%.

Additionally, the average copayment for a preferred drug for the CSR73 plan was $44, with a 30% coinsurance rate. For the CSR87 plan, $34 in copayment and 27% in coinsurance rate were recorded, while the CSR94 plan faced $28 in copayment and 24% in coinsurance rate.

For the 3 plans (CSR73, CSR87, and CSR94), the average copayment for a nonpreferred drug was $81, $67, and $57, respectively, with coinsurance rates of 36%, 34%, and 31%, respectively. Lastly, for the 3 plans, the average copayment for specialty medications was $174, $156, and $120, respectively, with coinsurance rates of 35%, 31%, and 27%, respectively.

Data for this analysis were collected from the Data.HealthCare.gov 2015 QHP Landscape file titled, “Health plan information for individuals and families,” which was based on information recorded as of January 26.—Kerri Fitzgerald