An Analysis of Cost Sharing for Prescription Drugs and Physician Services Under the Affordable Care Act


Breakaway Policy Strategies in collaboration with the Robert Wood Johnson Foundation has been tasked with gathering and analyzing detailed health insurance benefit designs and cost-sharing data for all 50 state marketplaces, plus the District of Columbia.

On December 10, 2013, Breakaway presented their preliminary findings at the American Bar Association’s Health Law Summit in Washington, D.C. The presentation provided a brief overview of Breakaway’s ACA Health Insurance Exchange Project and previewed early analysis on exchange plan benefit designs and cost sharing. These initial analyses consisted of reviews of cost sharing and benefit design data, gathered from state and federal government-sponsored exchange websites, for Bronze and Silver-level exchange plans from up to 20 states.

Key Findings

  • Average copayment for primary care physician visit is $30; average copayment for specialist visit is $47.

  • Average combined deductibles range from $2,000-$4,061.

  • Most Bronze, and close to half of Silver plans, apply deductible before any prescription coverage.

This presentation expands on Breakaway's preliminary report released in November 2013—Looking Beyond Technical Glitches—that analyzed premium and cost-sharing data for Silver-level plans in 15 states. The report included average and ranges of premiums, deductibles and copayment amounts, and coinsurance applicable to in-network primary care physician and specialist visits.