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Impact of exchange plan cost-sharing still a hot topic

July 08, 2013


As the picture of coverage on the exchange becomes clearer for Californians, the reality of the costs associated with exchange plans is beginning to set in for stakeholders.


As part of Covered California’s recent release of the plans that will be offered through the exchange, they again drove home the point to consumers that these plans come with significant cost-sharing obligations. (See table below.)



Consumer stakeholders at recent exchange meetings have underscored the importance of informing consumers that exchange coverage will not be comparable to Medi-Cal coverage in terms of patients’ out-of-pocket costs. A backlash from consumers around affordability could be a significant setback to enrollment efforts.


For those receiving subsidies to purchase coverage on the exchange (individuals making up to approximately 300 percent of the federal poverty level in most areas of the state – $34,470 for an individual and $12,060 for each additional family member), just meeting the deductible could be a significant challenge.


Beyond the deductible, relatively high copays for specialist office visits and imaging could result in reduced treatment plan adherence by patients. The drug deductibles and copays could also lead to many prescriptions being left at the pharmacist’s counter. Enhanced diligence by physician practices may be warranted to ensure exchange patients adhere to the course of treatment.


In the May issue of Health Affairs, a study of families who purchased coverage through the Massachusetts Connector, the model for Affordable Care Act's exchanges, found high levels of financial burden and higher-than-expected costs among some enrollees. Unsurprisingly, these burdens were significantly higher for families with two or more children, families with a member in poor health, and families below 400 percent of the federal poverty level. The authors of the study cautioned states to consider additional measures to ensure potential exchange plan enrollees fully understand the cost-sharing and premiums of a health plan.


Finally, until the exchange population’s reaction to this cost-sharing burden is better understood, physician practices should be attentive to the rates they are being paid by exchange plans, because unpaid patient cost-sharing effectively becomes a rate reduction for the practice.

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