Seeing Your Doctor: What To Expect With Exchange Market Coverage

An Examination of Physician Visit Cost Sharing and Benefit Design in the ACA Health Insurance Exchanges

Research into plan cost sharing for primary care physician (PCP) and specialist visits uncovers wide variation in plan deductibles, copayment and coinsurance amounts, and unique plan design features.

The Issue

The analysis is based on HIX Compare data for plans available in the 10 states reporting the highest exchange plan enrollment in 2015: Florida, California, Texas, North Carolina, Georgia, Pennsylvania, New York, Virginia, Illinois, and Michigan.

Key Findings

  • Unlike most employer-sponsored insurance plans, many exchange plans subject PCP and specialist visits to a deductible.

  • Cost sharing for PCP and specialist visits vary significantly among and within states.

  • From 2014 to 2015, cost-sharing amounts for PCP and specialist visits did not change dramatically. However, more plans shifted to utilizing copayments as compared to coinsurance for these services.

Conclusion

Some plans include unique design features that utilize copayment/coinsurance combinations, limited the number of free or discounted visits, and visit limitations. These designs likely reflect insurers’ ongoing efforts to comply with ACA requirements while keeping premiums low enough to attract enrollees.

 

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.

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