Cost-Sharing for Plans Offered in the Federal Marketplace for 2019
Most health plans require enrollees to pay a portion of the cost when they use services. While there are many forms of cost-sharing — deductibles, copayments, coinsurance – people often focus on the deductible amount because it provides a simple indication of how generous a plan may be. A deductible is the amount that an enrollee must pay toward the cost of in-network covered services before the plan will start paying for most types of care. The average deductibles for Marketplace plans in 2019 are largely similar to the deductibles seen in 2018 for most metal levels. Marketplace plans are grouped into four metal levels, based on their “actuarial value” – the average share of health care expenses that the plan covers for a typical group of enrollees. Plans may use different forms of cost-sharing to achieve the actuarial value levels specified in the ACA. Bronze plans have an actuarial value of 60% and therefore higher cost-sharing on average than either silver plans (70%), gold plans (80%) or platinum plans (90%).
Deductible amounts are shown separately for plans where medical spending and prescription drug spending are both subject to the same deductible (called “combined) and for plans where there are separate deductibles for medical spending and prescription drug spending (called “separate”). Not surprisingly, deductibles tend to decrease as one moves from the levels with lower actuarial values (“Bronze” and “Silver”) to the higher levels. Many people in Marketplace plans receive cost-sharing reductions (CSR), which reduce the amount of cost-sharing enrollees are required to pay. CSRs increase the actuarial value of silver plans for low-income enrollees, increasing the amount of health care expenses that the plan covers and therefore decreasing patient cost-sharing. Insurers must increase the actuarial value to 94% for enrollees with incomes below 150% of poverty, to 87% for enrollees with incomes between 150% and 200% of poverty, and to 73% for enrollees with incomes between 200% and 250% of poverty. While the federal government has terminated payments to insurers to compensate for the added cost of providing reduced cost-sharing to low-income enrollees, insurers are still required to offer CSRs in 2019. CSRs significantly decrease the average deductible an eligible enrollee is required to pay; For example, an enrollee below 150% of the federal poverty line (FPL) faces an average combined deductible of $239 compared to $4,375 for an enrollee above 250% of FPL.
Information on plan cost-sharing provisions was downloaded from Healthcare.gov for the plans offered in federally-facilitated and partnership exchanges. Because many plans are offered in multiple rating areas within a state, we reduced the number of plans so that each benefit package was counted only once for each state. The averages and distributions are simple averages of the plans that are available and are not weighted by enrollment because we do not have enrollment for each plan. Information for “expanded bronze” and “bronze” plans are reported together.