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ACA exchange plans' cost-sharing methods vary widely

New regulations for 2016 give private insurance providers a bit of wiggle room, but prevent cost-sharing increases

Health plans sold to individuals through Healthcare.gov for 2016 vary in how they set cost-sharing for services such as physician visits, prescription drugs and hospital stays, according to a new issue brief from the Kaiser Family Foundation.

The Affordable Care Act requires exchange plans to cover essential health benefits and puts limits on out-of-pocket cost maximums, tightening standardization among health plans, according to the brief.

But while the ACA requires private plans sold to individuals to standardize their coverage, insurers take different approaches to meeting the requirements. Some plans have large deductibles with little cost-sharing after the deductible has been met, while others have no or small deductibles but require patients to pay a substantial percentage of the cost at the point of service through high coinsurance rates. Aside from premiums, deductible prices are the main factor consumers look for when shopping for a plan, and the majority of bronze plans and silver plans have a single deductible for both medical services and prescription drugs, according to the brief.

Most plans have some form of cost sharing that applies to inpatient services as well. The interaction between cost-sharing for hospitalization and any general medical deductible for the plan can be extremely confusing, the brief notes, and some plans have a separate deductible or sizeable copayment that applies to the hospital stay, but do not apply to the general medical deductible.

Physician office visits, emergency department visits and prescription drug plans are also sources of cost-sharing in some plans, usually with deductibles, depending on what kind of treatment is needed.

While low-income individuals are constantly being encouraged to shop around for plans to reduce their cost-sharing responsibilities, greater cost-sharing does not necessarily encourage individuals to shop around, FierceHealthPayer previously reported. Additionally, the brief adds that enrollees should consider the cost of using their plan as well as the premium when they shop for coverage.

To learn more:
- here is the Kaiser Family Foundation brief

Related Articles:
Cost sharing varies widely for low-income exchange members
High-deductible plans reduce use of health services, study finds
HHS: Consumers who shop around save money