Cost sharing varies for low-income exchange members

June 6, 2014

Cost-sharing is not being lowered for other treatments and services, particularly specialty drugs

Low-income consumers who received subsidies to purchase plans in the exchanges are experiencing inconsistent reductions in spending depending on their selection. While almost all plans reduce deductibles and out-of-pocket caps in cost-sharing reduction (CSR) plans, many are not lowering cost-sharing for other treatments and services, particularly specialty drugs, according to data from Avalere Health.

“As stakeholders continue to push for more transparency in coverage and costs, managed care executives should consider how increased access to these details will affect plan choice by consumers and the resulting risk profile of enrollees,” says Caroline Pearson, vice president at Avalere Health. “Executives should prepare for the possibility that the federal government and state exchanges could increase requirements to standardize the methodology for reducing cost-sharing for the CSR plans, though this is unlikely prior to 2016 at the earliest.”

For 2014, payers focused reductions in cost-sharing mainly to overall plan structures, such as deductibles and maximum out-of-pocket limits. Lower cost-sharing for specific services was more prevalent for benefits such as primary care visits and preferred brand drugs than for others, including non-preferred brand and specialty tier drugs, according to Avalere. 

Avalere also found that average maximum out-of-pocket limits in CSR plans are lower than those required by the Affordable Care Act. Specifically, among 87% AV CSR plans, the average out-of-pocket limit is $450 (or 20%) lower than required, while among 94% AV CSR plans, the average out-of-pocket maximum is $1,140 (or 22%) less.

Pearson says managed care executives should be prepared that advocates and other healthcare stakeholders will push for policy changes to ensure their preferred services to receive higher subsidies. 

“Brand and specialty drugs are among the least likely services to have reduced cost-sharing for subsidized enrollees," she says.