Analysis: Cost-sharing stays stable in ACA marketplace plans

For the most part, cost-sharing did not increase for those covered under Affordable Care Act marketplace plans in 2015, though for those without cost-sharing reductions, average copayments, deductibles and out-of-pocket limits were considerably higher than the average employer-based plan, according to a new analysis from The Commonwealth Fund.

In examining eight types of cost-sharing in marketplace plans, the analysis found that only two increased overall from 2014 to 2015: out-of-pocket limits rose by nearly 2 percent, and copayments for non-preferred drugs rose by nearly 3 percent. 

Out-of-pocket limits for marketplace plans declined by 1.7 percent overall, and for households that earned 250 percent or more of the federal poverty level, the Department of Health and Human Services raised out-of-pocket limits about 3.2 percent during that period. Platinum plans saw the largest increase at 4.3 percent, while catastrophic plans had the sharpest decline, decreasing by 3.6 percent. In contrast, out-of-pocket limits increased on average in employer plans by 4.6 percent.

When examining copayments, the study found that visits to specialty clinics are more costly for ACA plans, averaging $52 per visit, which is significantly higher than the $36 average under employer-based coverage. Copayments for non-preferred drugs are considerably lower for employer-based plans than under marketplace plans for all formulary tiers except generics, the analysis found.

Finally, the study revealed that deductibles remained relatively unchanged for marketplace plans, though there were slight variations in both directions, depending on what plan was examined. For employer-based coverage, the average deductible in 2014 was $1,217, or the equivalent of a gold plan obtained through an ACA marketplace. High deductibles in employer-based plans can lead employees to cut back on healthcare services, previous research has shown.

New regulations for 2016 prevent cost-sharing increases, but since the ACA requires private plans sold to individuals to only standardize their coverage, that means insurers take different approaches to meeting these requirements, FierceHealthPayer has reported. 

To learn more:
- here is the Commonwealth Fund analysis