Cost sharing varies widely for low-income exchange members

The Affordable Care Act requires both state-based and federal exchanges to offer cost-sharing reductions (CSR) to low-income enrollees. But insurers have varying interpretations of meeting cost-sharing requirements, according to a new analysis from consulting firm Avalere Health.

Avalere looked at the federally-facilitated exchange in 34 states and found substantial differences in how insurers adjust cost sharing for benefits to reach the required "metal levels", or actuarial values (AV), and lower maximum out-of-pocket (MOOP) limits.

Plans in FFM states are not required to reduce cost sharing for all covered benefits or to do so evenly across benefits. Thanks to such flexibility, medical deductibles in the standard silver and CSR plans vary considerably across plans. Plans also vary in whether and how they alter cost sharing across drug formulary tiers.

"Many people assume that the lowest-income exchange enrollees will have reduced cost sharing across all services, but the reality is quite different," Caroline Pearson, vice president at Avalere, said yesterday in a statement. "For example, consumers may not experience reduced cost-sharing amounts for drugs or physician visits in many plans."

The analysis also found many CSR plans have MOOP limits lower than the amount required by law. For primary care physician visits, average cost sharing decreases as the AV level increases. Fewer insurers reduce cost sharing for specialist visits in CSR plans relative to the standard silver plan than they do for PCP visits.

The pharmaceutical industry has expressed concerns that cost sharing within most exchange plans could limit consumers' access to necessary medications. While specialty drug copays average $80 for employer-sponsored plans, consumers will pay $159 for silver plans and $157 for bronze plans for the same medications.

Meanwhile, Aaron E. Carroll, professor of pediatrics at Indiana University School of Medicine has argued against applying cost sharing to all insurance beneficiaries equally. He pointed to a recent JAMA Pediatrics study that found high cost sharing led children with a manageable chronic condition (asthma) to delay or even skip recommended care.

For more:
- read the Avalere statement and analysis (.pdf)