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Marketplace Health Plan Options for People with HIV Under the ACA: An Approach to More Comprehensive Cost Assessment

The Affordable Care Act (ACA) has expanded access to health coverage for millions of individuals, including people with HIV.1  One key expansion is the availability of new private insurance coverage through health insurance marketplaces in every state. As individuals shop for private insurance coverage in the marketplace, multiple factors go into selecting a health plan. While these factors include clinical considerations, the cost of coverage, particularly that relating to premiums, is driving much of consumer decision-making. For people with HIV, cost considerations take on added importance given their reliance on expensive antiretroviral prescription medications and the fact that cost may present a barrier to maintaining health coverage, which could adversely affect their health. Assessing premiums alone, however, may not provide an accurate measure of plan affordability and enrollees may find that they face unexpected or higher costs if premiums are used to guide plan selection in isolation. A more comprehensive assessment of the cost of coverage includes factors beyond just premiums, such as deductibles, drug costs, and out-of-pocket (OOP) maximums. Considering broader health plan costs is not only important for individuals with HIV but also for third party payers, such as the Ryan White HIV/AIDS Program, the nation’s safety net program for HIV care and treatment, which in many cases assists lower income clients with costs related to insurance coverage.2

This analysis provides estimates of the costs HIV positive individuals might expect to face when enrolled in marketplace health plans and describes the characteristics of plans that might offer the greatest value.

Altogether, costs in 300 different enrollment scenarios are examined, looking at 5 plans in each of five states for two enrollee types across various incomes. The enrollee types consist of one HIV positive individual with well managed HIV disease and no other chronic health needs and one HIV positive individual with significant HIV care needs and comorbidities. Costs are examined using two measures:

  1. Expected health costs: The total costs an HIV positive enrollee would anticipate facing in order to meet known drug treatment and care needs within a plan year, along with the cost of premiums.
  2. Total OOP liability: The greatest amount an individual would have to pay out-of-pocket, essentially the financial risk, within a given plan year, including both total annual premium amount and the plan’s out-of-pocket maximum.3
Key findings include:
  • If an enrollee or third party payer’s main objective is keeping costs low, assessing premiums alone may not be sufficient. The plans with the lowest premiums examined here were not, in most cases, the most cost-effective plan option based on either of the cost measures used in this analysis.
  • This analysis suggests that enrollees at the lowest income levels, who have the greatest access to cost-sharing reduction (CSR) subsidies, could find the lowest expected costs in silver level plans, at least based on the scenarios here. Thus looking at both plan metal level and enrollee income may be helpful in making enrollment decisions. However, for those with higher income levels, including those with access to some level of subsidies, the metal tier plan offering the best value was highly variable.
  • In looking across the scenarios in this report, those at the lowest income level generally paid a greater share of their income towards health care costs compared to those at the highest income level. However, if enrolled in the more cost-effective silver level plans, this could be minimized
  • Commonly, silver plans provide the least liability for those at lower incomes while platinum plans provided the least liability for those with higher incomes, suggesting the importance of enrolling in a high actuarial value plan when limiting financial risk is a goal.
  • Overall, the plan that would offer an enrollee the lowest expected health costs aligned with the plan providing the least OOP liability about half the time, enabling enrollees to both minimize expected costs and OOP liability. However, when this alignment does not occur, decisions are more complicated and enrollees or third party payers must assess the trade-off between reducing overall liability by paying more up front in known costs compared with paying less in known costs but having higher liability should unexpected costs arise.
  • The plan an enrollee selects has significant consequences for their expected health costs. On average there was a $4,054 difference between what an enrollee could expect to pay annually if enrolled in the plan with the lowest expected health costs compared to the plan with the highest. There was a $3,914 difference in liability between what an enrollee could expect to face annually if enrolled in the plan with the lowest liability compared to the plan with the highest, on average.
  • While on average cost those with higher health needs could expect to pay an additional $400 to meet known health costs compared to those with lower health needs, this amount ranged substantially at the individual level. For example, the amount of additional spending faced by a high utilizer enrollee (compared to the low utilizer enrollee in the same plan) ranged from nothing at all to $1,693. In 37 scenarios (12% of the time) the high utilizer enrollee faced more than $800 in additional expected health costs compared with the low utilizer enrollee.

While it is important for HIV positive enrollees and third party payers, including Ryan White grantees, to include other considerations in plan selection (such as whether drug regimens are covered -and at what level and with what utilization management requirements- whether specialty providers are in-network, and the role of the deductible in plan benefit design), it is reasonable to expect costs considerations to continue to drive some decision making. Overall, this analysis suggests that there is significant importance in making more comprehensive assessments of costs, beyond that of premiums alone, when making enrollment decisions.

Issue Brief

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Filling the need for trusted information on national health issues, the Kaiser Family Foundation is a nonprofit organization based in Menlo Park, California.