Marketplace Health Insurance Plans More Likely to Carry Deductibles for Prescription Drugs


Out-of-pocket limits significantly higher under ACA bronze and silver plans than with employer-based plans.

A recent study by The Commonwealth Fund examined whether cost-sharing for individual and family plans obtained under the state and federal marketplaces increased from 2015 to 2016.

Researchers analyzed data from platinum, gold, silver, and bronze plan tiers, as well as all tiers from 40 states and Washington, DC. Furthermore, because employers have turned to high-deductible plans as a major cost-control strategy, the cost-sharing for employer-based plans was also analyzed.

Excluded from the study was silver level plans with cost-sharing reductions available for low income individuals. The data used was for plans that are offered instead of purchased, since enrollment data for purchased plans is unavailable.

The study looked at 7 types of cost-sharing plans that included out-of-pocket limit; general annual deductible; copayment for primary care provider visit; copayment for specialty visit; copayment for generic drugs; copayment for preferred-brand drugs; and copayment for non-preferred brand drugs.

Researchers found that copayments for generic drugs decreased by 3% in 2016. There were 3 types of cost-sharing that had a significant increase, which included a 7% increase in out-of-pocket limits, a 10% increase in general annual deductibles, and a 14% increase in copayments for non-preferred drugs.

According to researchers, the overall figures may not be completely reflective of a given plan’s year-to-year changes in cost-sharing, since the increase in bronze and silver plans and the decrease in gold and platinum plans could be a contributing factor to the increase in the average deductibles and out-of-pocket costs.

Typically, actuaries believe that the size and presence of deductibles is the most important determinates of cost-sharing expenses by enrollees, the study noted. Researchers found that in 2016, the proportion of marketplace plans with a general annual deductible ranged from 40% of the platinum plans to almost 100% of the bronze plans. In 2015, 81% of employer-based plans had general deductibles.

Since there was a change in plans from 2015 to 2016, with the share of platinum and gold plans slightly declining while silver and bronze plans increased slightly, it caused the annual deductibles to change with the plan tiers (except for the bronze plans) becoming smaller than the overall 10% deductible change. This demonstrated a shift in the market towards higher deductible plans.

There are numerous plans sold that do not require enrollees to meet their deductible first before their coverage starts. Marketplace plans included in the analysis that required people to first meet their deductible ranged from 6% for platinum to 51% for bronze plans.

Overall, the proportion of marketplace plans that required a deductible for primary care office visits decreased from 2015 to 2016 across all tiers, but the decreases were found to be largest in the gold and bronze plans.

Prescription drug coverage plans that required enrollees to meet their deductible first ranged from 26% for platinum to 82% for bronze plans compared with 11% for employer-based plans. The percentages increased for the silver, gold, and platinum plans in 2016, with the largest increase seen in the platinum plans. Bronze plans that required a deductible decreased by 10%.

Under marketplace plans, copayments are considered a major part of the costs for office visits. The study revealed the ratio of plans that required copayments to the requirement of coinsurance 4 to 1 for primary visits and 3 to 1 for specialty care visits.

The average copay cost of primary care visits ranged from $17 for platinum plans to $43 for bronze plans. The average copayment across all plans was similar to the average 2015 employer-based plans ($29 and $24, respectively).

When it comes to out-of-pocket limits, they are put in place to protect enrollees from astronomical bills. In 2016, the average limit for all plans increased by 7% from 2015, ranging from 3% for bronze plans to 16% for platinum plans. The 2016 cap for out-of-pocket limits is $6850 for individual coverage and $13,700 for family coverage, which is a 4% increase from 2015.

The most predominant form of cost-sharing for generic drugs is copayments, however, the use of copayments decreases when used for expensive drugs while the use of coinsurance increases.

The higher the plan tier, the more plans require copayments for prescription medications instead of coinsurance. The proportions range from 35% for bronze to 94% for platinum plans.

Additionally, as drug prices increase so does the average copayment, which ranges from $12 for generic drugs to $252 for specialty drugs.

The copayments were considerably lower under the employer-based plans than all formulary tiers under the marketplace plans, other than for generic drugs.

More than 40% of marketplace enrollees who do not receive cost-sharing reductions saw a moderate increase in cost sharing from 2015 to 2016.

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