Last Updated- March 2016:

Medical Deductibles and Out-of-Pocket Limits

How does cost-sharing vary among plans offered on HealthCare.gov in 2016?

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Overview

For the 2016 coverage year, consumers in 38 states can use HealthCare.gov to shop for Qualified Health Plans (QHPs) (referred to here as “plans”). As with most health insurance options, plans offered through HealthCare.gov require consumers to pay for a portion of the health care services they receive. These cost-sharing provisions typically include an annual deductible, co-pays and/or co-insurance. The Affordable Care Act (ACA) limits the maximum amount that a plan can require a consumer to pay for these out-of-pocket costs each year.


To illustrate how cost-sharing expenses vary around the country, this ACA Spotlight displays by county the median medical deductible and out-of-pocket limit for plans offered in each of the coverage categories on HealthCare.gov in 2016. See the background section for more details about cost-sharing and the methodology section for more information on the data used.

At-A-Glance: State Marketplace Decisions

State Marketplace Type* Enrollment Website**
Alabama Federally-facilitated Marketplace healthcare.gov
Alaska Federally-facilitated Marketplace healthcare.gov
Arizona Federally-facilitated Marketplace healthcare.gov
Arkansas State-Partnership Marketplace healthcare.gov
California State-based Marketplace coveredca.com
Colorado State-based Marketplace connectforhealthco.com
Connecticut State-based Marketplace accesshealthct.com
Delaware State-Partnership Marketplace healthcare.gov
District of Columbia State-based Marketplace dchealthlink.com
Florida Federally-facilitated Marketplace healthcare.gov
Georgia Federally-facilitated Marketplace healthcare.gov
Hawaii Federally-supported State-based Marketplace healthcare.gov
Idaho State-based Marketplace yourhealthidaho.org
Illinois State-Partnership Marketplace healthcare.gov
Indiana Federally-facilitated Marketplace healthcare.gov
Iowa State-Partnership Marketplace healthcare.gov
Kansas Federally-facilitated Marketplace healthcare.gov
Kentucky State-based Marketplace kynect.ky.gov
Louisiana Federally-facilitated Marketplace healthcare.gov
Maine Federally-facilitated Marketplace healthcare.gov
Maryland State-based Marketplace marylandhealthconnection.gov
Massachusetts State-based Marketplace mahealthconnector.org
Michigan State-Partnership Marketplace healthcare.gov
Minnesota State-based Marketplace mnsure.org
Mississippi Federally-facilitated Marketplace healthcare.gov
Missouri Federally-facilitated Marketplace healthcare.gov
Montana Federally-facilitated Marketplace healthcare.gov
Nebraska Federally-facilitated Marketplace healthcare.gov
Nevada Federally-supported State-based Marketplace healthcare.gov
New Hampshire State-Partnership Marketplace healthcare.gov
New Jersey Federally-facilitated Marketplace healthcare.gov
New Mexico Federally-supported State-based Marketplace healthcare.gov
New York State-based Marketplace healthcare.gov
North Carolina Federally-facilitated Marketplace healthcare.gov
North Dakota Federally-facilitated Marketplace healthcare.gov
Ohio Federally-facilitated Marketplace healthcare.gov
Oklahoma Federally-facilitated Marketplace healthcare.gov
Oregon Federally-supported State-based Marketplace healthcare.gov
Pennsylvania Federally-facilitated Marketplace healthcare.gov
Rhode Island State-based Marketplace healthsourceri.com
South Carolina Federally-facilitated Marketplace healthcare.gov
South Dakota Federally-facilitated Marketplace healthcare.gov
Tennessee Federally-facilitated Marketplace healthcare.gov
Texas Federally-facilitated Marketplace healthcare.gov
Utah Federally-facilitated Marketplace healthcare.gov
Vermont State-based Marketplace healthconnect.vermont.gov
Virginia Federally-facilitated Marketplace healthcare.gov
Washington State-based Marketplace wahealthplanfinder.org
West Virginia State-Partnership Marketplace healthcare.gov
Wisconsin Federally-facilitated Marketplace healthcare.gov
Wyoming Federally-facilitated Marketplace healthcare.gov

* See Kaiser Family Foundation here.

** See healthcare.gov here.

Background

The ACA established HealthCare.gov as a resource for people in states that do not have a state-based health insurance marketplace to purchase and enroll in plans. Like with most health insurance options, plans offered through HealthCare.gov require consumers to pay for a portion of the health care services they receive. These cost-sharing provisions include:


  • Deductibles: The amount a consumer owes for covered health care services before the insurer begins to pay for any expenses. Plans pay for certain health care services before the consumer has met his or her deductible, such as preventative services.
  • Coinsurance: A consumer’s share of the costs of a covered health care service, calculated as a set percentage (for example, 20%) of the allowed amount for the service. A consumer starts paying coinsurance after he or she has met the deductible. A plan may use coinsurance, copayments, or both.

Consumers pay their portion of cost-sharing for covered services they receive in addition to their monthly premiums; generally, consumers will pay higher premiums for plans that require less cost-sharing and lower premiums for plans that require more cost-sharing.


The out-of-pocket limit for a plan caps what the consumer has to pay for services covered by the plan and received by in-network providers during a plan’s policy period (usually one year). After a consumer reaches this amount, the plan will pay the entire cost of most covered services for the rest of the policy period. This includes deductible expenses and may also include cost-sharing expenses that occur after the deductible is met (like copayment and coinsurance expenses). For 2016 plans offered through HealthCare.gov, the maximum out-of-pocket limit is $6,850 for an individual plan and $13,700 for a family plan.


Those with a silver category plan from HealthCare.gov and income between 100 and 250 percent of the federal poverty level (FPL) may qualify for cost-sharing reductions (CSR), a discount that lowers the amount a consumer pays towards cost-sharing. The plan categories are based on the percentage of cost for services covered under a plan that the insurer will pay for. For example, insurers pay about 70% of the costs for services covered under a silver plan. Cost-sharing reductions lower eligible consumers’ costs by increasing the share of costs the silver plan insurer pays for. The amount of cost-sharing reduction is based on income level:


  • Consumers with incomes between 100 and 150% FPL qualify for 94% cost-sharing reductions, meaning the silver plan will pay 94% of the cost of covered services on average.
  • Consumers with incomes between 150 and 200% FPL qualify for 87% cost-sharing reductions, meaning the silver plan will pay 87% of the cost of covered services on average.
  • Consumers with incomes between 200 and 250% FPL qualify for 73% cost-sharing reductions, meaning the silver plan will pay 73% of the cost of covered services on average.

These cost-sharing reduction options are referred to as 94% CSR, 87% CSR and 73% CSR in the Spotlight infographics on silver plans.


The plan categories are based on the percentage of cost for services covered under a plan that the insurer will pay for on average, but how those out-of-pocket costs are distributed among types of cost-sharing can vary significantly from plan to plan. For example:


  • One silver level plan may have a $1,750 deductible, $1 copay for physician visits, and no cost-sharing for inpatient care after the deductible is met.
  • Meanwhile, another silver plan may have a $200 deductible, but a $10 copay for physician visits and a $600 copay or 30% coinsurance for inpatient care after the deductible is met.

The specific out-of-pocket costs a consumer will pay under any plan will depend on the health care services the consumer uses in a year. Therefore, consumers cannot rely on the selection of a plan within a certain plan category to accurately predict how much they will ultimately spend; to get a more accurate prediction, they must also consider what health services they typically use and then consider a plan’s cost-sharing arrangement. HealthCare.gov now includes tools to help consumers make these estimates.

Methodology

The infographics in this ACA Spotlight illustrate how cost-sharing varies among HealthCare.gov’s 2016 plan choices by county. Spotlight users first select among one of the following plan categories: catastrophic, bronze, silver, gold, or platinum. They then select if they want to see the median for an individual’s medical deductible, a family’s medical deductible, an individual’s out-of-pocket limit, or a family’s out-of-pocket limit. For the silver plan category, Spotlight users are also able to select infographics that illustrate median deductibles or out-of-pocket limits offset by cost-sharing reductions. These cost-sharing reduction variants are referred to as 94% CSR, 87% CSR and 73% CSR in the Spotlight infographics on silver plans.


Social Interest Solutions (SIS) produced the data and infographics using the MAGI Cloud platform. The MAGI Cloud platform includes a comprehensive rules engine that can generate ACA eligibility results across all states and across the full spectrum of health insurance options, including Medicaid, the Children’s Health Insurance Program (CHIP), and QHPs with and without premium tax credits and cost-sharing reduction subsidies. To learn more about the MAGI Cloud platform, click here.


The MAGI Cloud platform uses HealthCare.gov 2016 plan data current as of December 22nd, 2015 to determine the median medical deductible or maximum out-of-pocket limit among the plans within a specified plan category offered in a county, based on the cost-sharing parameter the Spotlight user selects. This ACA Spotlight provides data on all 38 states in which consumers can use HealthCare.gov to shop for 2016 health plans. Catastrophic and/or platinum plans are not offered in certain areas.


Data used in this Spotlight are available upon request. Please email requests to info@socialinterest.org.

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