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July 30—Health insurance plans offered through government-run marketplaces come with higher consumer costs than enrollees may be used to in employer-provided health insurance plans, a comprehensive new analysis found.
The report—based on a data set of all 1,208 unique silver level plans offered through marketplaces created by the Affordable Care Act (ACA)—found wide variations in copayments and coinsurance for physician visits. The Robert Wood Johnson Foundation-funded report found the amount of copayments required in silver plans ranged from $0 to $75 for primary care physician (PCP) visits and from $10 to $150 for specialist visits. Coinsurance rates varied from 0 to 50 percent for PCP visits and from 8 to 100 percent for specialist visits.
The deductibles required for PCP and specialist visits are significantly higher than those in most employer-sponsored insurance plans, according to the report. Some marketplace plans also differ in the use of plan designs that combine copayments and coinsurance, or in the limits they impose on free or discounted visits or on visits overall.
Many of the unique design features of marketplace plans are part of insurers’ efforts to comply with ACA requirements while keeping premiums low enough to attract enrollees, according to researchers from Breakaway Policy Strategies, which conducted the analysis. They underscored that the findings mean consumers face a complicated plan selection process in which they need to consider provider options, application of deductibles, limits on visits, and total copayment/coinsurance costs.
The premium and cost-sharing figures included in the report do not account for ACA-sponsored cost-sharing reductions [CSRs] or premium subsidies for which many enrollees are eligible. For example, marketplace enrollees who purchase a silver-level plan and whose incomes do not exceed 250 percent of the federal poverty level are eligible for subsidies to help pay for out-of-pocket costs.
The difference can have major consequences for enrollees in marketplace plans, with silver plans featuring median combined deductibles of $2,267 and some silver plans had deductibles as high as $5,000, according to the report. “Some stakeholders have expressed concern that with deductibles at that level, even enrollees who qualify for premium subsidies and CSRs may not be able to afford the amounts that they would have to pay out of pocket before their plans begin to pay benefits for physician visits,” the report stated.
“Many enrollees, especially those who were previously uninsured, may not fully understand their new coverage and may not have realized that their plans only pay benefits if they obtain services from network providers,” the report stated.
Publication Date: Wednesday, July 30, 2014
Tom Myers, chief strategy officer, The SSI Group, discusses the shifting payment environment and how it affects providers' patient access and claims management processes.
Jeff Chester, senior vice president and chief revenue officer at Availity, shares his thoughts on "Revenue Cycle 2.0" and how to best meet its challenges.
Mitch Morris, vice chair and global leader, healthcare, Deloitte, and Michael O'Rourke, senior vice president and chief information officer, Catholic Health Initiatives (CHI), share perspectives on the need for transformational IT in health care today.
Brian Kueppers, founder and CEO, Apex, discusses the importance of a robust patient payment strategy in boosting organization revenue and enhancing patient satisfaction.
Brian Grazzini, CFO, HealthPort, describes the importance of efficient and compliant information exchange and audit management in helping HIM staff spend less time on paperwork and more on mission-critical projects.
Cindy Matthews, executive vice president, Community Hospital Corporation, discusses how rural and community hospitals can use collaborative partnering to position for success through tough market conditions.
Rick Heise, senior vice president, revenue cycle, at Cerner Corporation, discusses the importance of integrating clinical and financial data to excel in health care’s changing payment environment.
Russ Graney, founder and CEO for Aidin, and John Laursen, head of business development for Aidin, share insights on how to improve care transitions between acute and post-acute care settings and incentivize high-quality patient outcomes.
Scott Elston, strategic accounts manager, GE Healthcare Services, describes how substantial cost reduction in health care requires rethinking business strategy and asset use.
Robert Williams, MD, director, Deloitte Consulting LLP, and Arielle Freiberger, product strategist, ConvergeHEALTH by Deloitte, explain how sophisticated retrospective, real-time, and predictive data analytics can inform decision making to reduce costs and improve care.
Stuart Hanson, director of business development (healthcare solutions) at Citi Retail Services, discusses how improving the payment experience can benefit consumers and healthcare providers.
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