Report: Consumers in exchanges receiving federal assistance may experience inconsistent reductions

WASHINGTON – A new analysis from Avalere Health released Tuesday found that consumers in exchanges receiving federal assistance to reduce their out-of-pocket costs may experience inconsistent reductions in spending depending on the plan they choose. Specifically, the data show broad differences in how issuers amend plan designs to meet cost-sharing requirements for those receiving cost-sharing reductions. While almost all plans reduce deductibles and out-of-pocket caps in CSR plans, many plans do not lower cost-sharing for other treatments and services, particularly specialty drugs.

“Many people assume that the lowest-income exchange enrollees will have reduced cost-sharing across all services, but the reality is quite different,” said Caroline Pearson, VP Avalere Health. “While all plans must have reduced out-of-pocket limits for individuals earning less than 250% of poverty, how consumers will reach those limits differ significantly. For example, consumers may not experience reduced cost-sharing amounts for drugs or physician visits in many plans.”

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.

“Issuers will continue to have flexibility in how they design cost sharing reduction plans in 2015,” said Dan Mendelson, CEO Avalere Health. “Looking ahead, consumers who qualify for cost-sharing reductions should look closely at how the plan benefit is structured because it could have a major impact on their actual out-of-pocket costs.”

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