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Benefits and Cost-Sharing for Working People with Disabilities in Medicaid and the Marketplace

Appendix 2

Methodology for Selecting Representative QHPs for Cost-Sharing Analysis

Differences among states in terms of both Marketplace design choices and readily available public sources of information about Marketplace coverage led to slight differences in the methodology used to select the QHP in each state for purposes of the cost-sharing analysis. A silver level plan offered in 2014, in the county with the largest population in each state was selected, as that is the metal tier to which premium subsidies are tied. Specifically, the representative QHP was selected from the plans available for a single, 40 year old, non-smoker, with income at 145% FPL.

California has chosen to be an active purchaser in its state-based Marketplace and has standardized deductibles, out-of-pocket maximums, and co-payments for all QHPs in each metal tier. As a result, the silver level plan with the least expensive premium was selected for California. New Jersey and Ohio are both FFM states, and the silver plan with the least expensive premium was selected in each of these states.

Kentucky has a state-based Marketplace and as of spring 2014, did not provide information about premium tax credit or cost-sharing reduction amounts when presenting QHP information on its website. The Kaiser Family Foundation’s subsidy calculator was used to determine premium tax credit amounts for this analysis in Kentucky. Among the three insurers offering silver level plans in the county with the largest population in Kentucky in 2014, only one provided cost-sharing reduction information on the insurer’s own website. While there were plans with less expensive premiums for purchase in Kentucky, no cost-sharing reduction information for these plans was readily available. Among the five silver plans (offered by the same issuer) with cost-sharing information available, the plan with the second least expensive premium was selected as representative. This was due to differences in how cost-sharing is structured in the selected plan as compared to the plan with the least expensive premium. Specifically, the selected plan covers some services, such as three doctor’s visits and prescription drugs, with just a co-payment, without the need to first meet a deductible, while the plan with the least expensive premium for which cost-sharing reduction information was available applies the deductible to all covered services.

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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.