Take Two Aspirin: An Examination of Physician Visit Cost Sharing and Benefit Design in the New Health Insurance Marketplaces

This issue brief provides physician visit cost sharing and benefit design analysis for silver-level plans, including deductible information, copays and coinsurance ranges.  

The brief's data were taken from Breakaway Policy Strategies' comprehensive dataset, HIX Compare, containing:

  • Benefit design and cost sharing requirements for all 1,208 unique silver-level exchange plans.

Key Findings

  • Coinsurance ranges from 0 percent to 50 percent for primary care physician (PCP) visits, and from 8 to 100 percent for specialist visits.

  • Copayments range from $0 to $75 for PCP visits and $10 to $150 for specialist visits.

  • 68 percent of plans charge a copayment before the deductible for a PCP visit.

  • 32 percent of plans subject PCP visits to a deductible and 39 percent subject specialist visits to a deductible.

About The Grantee

Breakaway Policy Strategies provides research, analysis, practical advice and strategic solutions to guide stakeholders in navigating the transformative changes taking place in the American health care system.