What’s in a Number? Examination of 2015 Silver Plan Cost-Sharing Data

Staff portrait of Kathy Hempstead

Katherine Hempstead, PhD, MA, director and senior program officer, leads RWJF's work on health insurance coverage.

To help improve our understanding of the health insurance coverage available to consumers under the Affordable Care Act (ACA), the Robert Wood Johnson Foundation worked with Breakaway Policy Strategies to produce Health Insurance Exchange (HIX) Compare, which contains information about premiums, deductibles, out-of-pocket limits, and cost sharing for all silver plans sold on the new ACA exchanges. HIX Compare is the most comprehensive open source data available with information about plans in all 50 states, and provides an in depth look at choice, affordability and plan design features. Today, we are releasing HIX Compare for 2015, along with an analytical file that links plans for the last two years—this allows for the analysis of how exchange markets and individual plans have changed. We have also expanded the 2015 dataset to include data on Cost Sharing Reduction (CSR) plans, available to those eligible for marketplace plans with incomes under 250 percent of the federal poverty level.

Additionally, we are releasing several analytical briefs by Breakaway Policy Strategies that address some of the important questions raised by these data. Seeing Your Doctor examines physician visit cost sharing and benefit design for the 10 states reporting the greatest ACA enrollment in 2015 (FL, CA, TX, NC, GA, PA, NY, VA, IL and MI). We find a continuation of the same variation observed in 2014, with co-pays for primary care physician (PCP) visits ranging from $5 to $75 (with a median of $30) and for specialist visits ranging from $20 to $100, with a median of $50. For both PCP and specialist visits, coinsurance in these 10 states ranged from 10 percent to 50 percent, with a median of 30 percent. It would appear that the large variation in plan design observed in 2014 may have persisted to 2015, although it would take a more thorough analysis of all of the states and the distribution to be conclusive. Figure 1 suggests that while significant ranges persist in many states, the medians in these 10 states do not differ nearly as greatly. Additionally, the analysis of silver plans in these 10 states suggested that while cost-sharing amounts did not change significantly, overall plans were more likely to shift from coinsurance to copayments, as a way of imposing this cost sharing. Figure 2 shows a significant drop in the number of plans in these 10 states that used coinsurance. It would be interesting to see whether this change was limited to these 10 states, since earlier reports had seemed to suggest the opposite trend—toward more coinsurance. While nearly 40 percent of plans in these 10 states subject PCP and specialty visits to the deductible, this actually represents a slight decline from 2014—another finding which differs from prior reports suggesting that use of the deductible was increasing in 2015.

In Beyond Premium Subsidies, Breakaway takes a deeper dive into the Cost Sharing Reduction (CSR) data made available this year. The brief looks specifically at 73%, 87% and 94% actuarial value (AV) plans sold in the 10 states with the greatest enrollment. A major takeaway is that there were big differences in deductibles and out-of-pocket (OOP) maximums between the three categories of CSR plans, yet differences in cost sharing for services were quite a bit smaller. For example, Figure 1 shows median medical deductibles ranged from $100 for a 94% AV plan to $2,500 for a 73% plan, as compared with $3,000 for a standard silver plan. Similar gradations are evident with regard to the OOP maximum, as seen in Figure 2. Figure 3 shows median copayment and coinsurance amounts for PCP and specialty visits. For PCP visits, median co-pays in CSR plans range from $10 to $25, as compared with $30 for standard plans. Yet median coinsurance is 20 percent for all CSR plans, and 30 percent for standard plans. Figure 4 shows specialty care coinsurance is the same while median copayments range from $30 to $50 in CSR plans, as compared with $50 in standard plans. Figures 5 and 6 show a similarly compressed range in median copayments and coinsurance for generic and preferred drugs.

There was another interesting takeaway related to data availability on CSR plans. Information on these CSR plans came from the Centers for Medicare & Medicaid Services Public Use and Landscape files. For those plans sold on state based exchanges (SBES), data came either from summaries of benefits and coverage (SBC) found on the state websites, or when necessary, directly from the carrier website. Breakaway found that in SBEs, information on CSR plans was relatively hard to obtain. In particular they noted that SBCs were not available for some or all of the CSR plans in a number of the SBEs. This particular issue illustrates the larger point that the quality of publicly available plan data is much higher for the federally facilitated exchange (FFE) due to the availability of the Public Use and Landscape files. HIX Compare is one attempt to remedy this deficiency, but clearly more detailed data about plans sold in SBEs should be publicly available. Hopefully this issue will be addressed soon.

In Observations on Drug Formulary Structures in 2014 and 2015, Breakaway takes a closer look at changes in drug coverage on the exchange plans. One of their areas of focus relates to potentially higher prices for generic drugs, while the other concerns potentially lower prices for an emerging class of drugs sometimes designated as a “wellness” tier. There is a generally shared understanding among consumers that generic drugs are usually placed on Tier 1, preferred brand drugs on Tier 2, non-preferred drugs on Tier 3, and specialty drugs on Tier 4. One interesting finding relates to the formulary placement of generic drugs. In an examination of the 2015 SBE plans, Breakaway finds that in about half of the states, at least some carriers have plans where generics are placed on Tier 2, where there is greater cost sharing. This is interesting as it may be unexpected by consumers, and also might have interesting implications for carrier strategy with respect to pharmaceutical pricing, including costs for competitive brand products.  

Another focus of this brief concerns an emerging practice—the designation of a “wellness” tier for certain prescription drugs. This practice has also been noticed in the large group market. In order to examine it in the ACA exchanges, Breakaway focused on the SBE states where the manual extraction of information from the SBCs yielded more detailed data. Drugs on the “wellness” tier have special treatment under drug formularies—although there is much variation in this treatment, including first dollar coverage as well as exemption from the deductible. Issuers are not consistent in the manner in which this category of drugs is described, what drugs are included, and how they are priced. For some it includes preventive medications such as folic acid, contraception, and smoking cessation treatments. For others, the list is broader and includes major therapies for chronic conditions such as statins and hypertensives, as well as some mental health therapies. In some cases these drugs are provided with first dollar coverage, while in others there are other kinds of exemptions from cost sharing. Since deductibles and other types of cost sharing in health insurance are major concerns, this emerging tier should be highly relevant to consumers, although it is currently not consistently defined or widely understood.