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.

Deductibles Applied Differently

The report found that many marketplace plans require enrollees to meet their plan’s deductible before basic services such as physician office visits are covered. That practice is sharply at odds with most employer-provided coverage. 

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.

Plans Limit Providers

The report also found that among the 1,208 unique silver plans, 60 percent are either health maintenance organizations (535) or exclusive provider organizations (83), many of which require enrollees who seek care from a provider outside of the plan’s network to pay the entire cost of services. Most of the remaining plans (427) are PPOs, which may cover some services provided by out-of-network providers but require higher cost sharing.

“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.


Rich Daly is a senior writer/editor in HFMA’s Washington, D.C., office. Follow Rich on Twitter: @rdalyhealthcare.

Publication Date: Wednesday, July 30, 2014