The New ACA Health Insurance Exchanges

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1 The New ACA Health Insurance Exchanges Benefit Designs Relating to Prescription Medicines and Other Health Care Items and Services HEALTH

2 Overview of Presentation: Summary of National Data o o Executive Summary National Marketplace s Out-of-Pocket Maximums Cost Sharing o o o Prescription Drugs Physician Visits Emergency Room Visits 2

3 EXECUTIVE SUMMARY

4 and Plan Average Premiums are Comparable $3,167 $3,110 $1,858 $1,825 $263 $226 $126 $101 $448 $384 $228 $172 : 27-Yr Old : 27-Yr Old : 50-Yr Old : 50-Yr Old 4 *Sn: total number of plans **Bn: total number of plans High Low Average Sn = 7011 / Bn = 5869

5 Average s Most Plans Subject Rx to Sn = 1204 Nearly All Plans Subject Rx to Bn = % Average s Higher in Plans $4,986 27% 38% 17% $2,275 36% 76% $470 $956 Combined Separate Rx No for Rx Combined for Medical and Rx 5 Separate Rx *Combined deductible: A combined deductible means both medical and drug charges contribute to a total plan-level deductible **Separate Rx deductible: A separate Rx deductible means that drug charges contribute to a separate plan-level deductible ***23 plans have a zero dollar combined deductible and 251 and plans have a zero dollar separate Rx deductible **** Sn: total number of unique plans; Bn: total number of unique plans

6 Rx is More Often Subject to s in Plans Proportion of Plans Subjecting Rx to 3% 11% 38% 24% 24% No for Rx All Rx Subject to All Brand Subject to Some Brand Subject to Only Specialty Subject to Proportion of Plans Subjecting Rx to ** 2% 1% 23% 57% 17% 6 *Data is for both combined and separate Rx deductibles **Two bronze plans do not fit into the categories highlighted above, because they subject generic and preferred brand Rx to the deductible but exempt specialty Rx

7 Dollars Average Combined s $7,000 $6,000 $5,000 $5,517 $4,808 $5,435 $5,785 $5,215 $4,000 $3,000 $2,000 $1,000 $2,098 $2,301 $2,163 $2,535 $2,391 $0 No for Rx All Rx Subject to All Brand Subject to Some Brand Subject to Only Specialty Subject to 7

8 Dollars Median Combined s $7,000 $6,000 $5,000 $6,000 $5,000 $5,600 $5,750 $5,500 $4,000 $3,000 $2,000 $2,000 $2,000 $2,000 $2,450 $2,125 $1,000 $0 No for Rx All Rx Subject to All Brand Subject to Some Brand Subject to Only Specialty Subject to 8

9 Dollars Average Separate Rx s $1,400 $1,305 $1,200 $1,000 $910 $930 $1,050 $800 $600 $400 $442 $500 9 $200 $0 All Rx Subject to All Brand Subject to No bronze plans Some Brand Subject to o 266 plans list a separate Rx deductible but do not subject any Rx to the deductible. In most cases the deductible is $0, however 17 plans list a separate Rx deductible with the average being $20. o 32 plans list a separate Rx deductible but do not subject any Rx to the deductible. In most cases the deductible is $0, however 6 plans list a separate Rx deductible with the average being $55. No bronze plans Only Specialty Subject to

10 Dollars Median Separate Rx s $1,200 $1,000 $1,000 $1,000 $1,000 $800 $750 $600 $400 $400 $500 $200 $0 All Rx Subject to All Brand Subject to No bronze plans Some Brand Subject to No bronze plans Only Specialty Subject to 10 o 266 plans list a separate Rx deductible but do not subject any Rx to the deductible. In most cases the deductible is $0, however 17 plans list a separate Rx deductible greater than $0. o 32 plans list a separate Rx deductible but do not subject any Rx to the deductible. In most cases the deductible is $0, however 6 plans list a separate Rx deductible greater than $0.

11 Nearly All and Plans Have a Combined Out-of-Pocket Maximum Proportion of Plans with Combined vs. Separate Rx OOP Maximum Sn = 1204 Average: $1,503 4% Proportion of Plans with Combined vs. Separate Rx OOP Maximum Bn = 1056 Average: $2, % 96% Average: $5, % Average: $6,291 Combined OOP Maximum Separate Rx OOP Maximum 11 *Sn refers to the total number of unique plans **Bn refers to the total number of unique plans

12 Percent of Plans with Coinsurance by Tier 69% 61% 36% 41% 44% 25% 24% 11% Generic Sn=132 / Bn=260 Preferred Brand Sn=286 / Bn=381 Non-Preferred Brand Sn=486 / Bn=459 Specialty Sn=811 / Bn= *Cost sharing patterns may differ if service is subject to a deductible **Sn: total number of plans that charge coinsurance ***Bn: total number of plans that charge coinsurance

13 Average Cost Sharing in Each Tier Average Copays Average Coinsurance $98 $84 $159 $157 $80 32% 28% 31% 37% 25% 41% 39% 38% 33% 35% 32% $58 $47 $52 16% $13 $18 $10 $29 Generic Preferred Brand Non-Preferred Brand Specialty Generic Preferred Brand Non-Preferred Brand Specialty Employer Average 13 *Cost sharing patterns may differ if service is subject to a deductible ESI Cost Sharing Source: Kaiser Family Foundation, 2013

14 Plans Almost Twice as Likely as to Use Copays for Primary Care Visit Plan PCP Visit Cost Sharing Plan PCP Visit Cost Sharing Average PCP Cost Sharing 7% 21% $31 $38 25% 33% 22% 44% 71% 43% Copayment Coinsurance Copayment Coinsurance No Cost Sharing* 14 *No Cost Sharing: Plans charge $0, 0%, or list no charge as applicable cost sharing for an individual. This generally applies after the deductible has been met

15 Plans Almost Twice as Likely as to Use Copays for Specialist Visits Plan Specialist Visit Cost Sharing 25% 7% Plan Specialist Visit Cost Sharing 23% 32% $57 Average Specialist Cost Sharing $71 34% 25% 70% 48% Copayment Coinsurance Copayment Coinsurance No Cost Sharing* 15 *No Cost Sharing: Plans charge $0, 0%, or list no charge as applicable cost sharing for an individual. This generally applies after the deductible has been met

16 Plans Twice as Likely as to Use Copays for Emergency Room Visits Plan ER Cost Sharing Plan ER Cost Sharing Average ER Cost Sharing $392 35% 6% 26% 30% $300 25% 47% 60% 54% Copayment Coinsurance Copayment Coinsurance No Cost Sharing* 16 *No Cost Sharing: Plans charge $0, 0%, or list no charge as applicable cost sharing for an individual. This generally applies after the deductible has been met

17 NATIONAL MARKETPLACE

18 Assessment of Common Marketplace Plan Features o Majority of silver and bronze plans Offer a combined deductible Subject all or some Rx to the deductible o plans also tend to subject other services such as physician visits and inpatient hospital stays to the deductible Have a combined out-of-pocket maximum Charge copayments for primary care physician visits Designate a specialty tier o Some plans designate a specialty tier but state that cost sharing varies by the drug prescribed Charge coinsurance for specialty drugs 18

19 DEDUCTIBLES

20 Average s Most Plans Subject Rx to Sn = 1204 Nearly All Plans Subject Rx to Bn = % Average s Higher in Plans $4,986 27% 38% 17% $2,275 36% 76% $470 $956 Combined Separate Rx No for Rx Combined for Medical and Rx 20 Separate Rx *Combined deductible: A combined deductible means both medical and drug charges contribute to a total plan-level deductible **Separate Rx deductible: A separate Rx deductible means that drug charges contribute to a separate plan-level deductible ***23 plans have a zero dollar combined deductible and 251 and plans have a zero dollar separate Rx deductible **** Sn: total number of unique plans; Bn: total number of unique plans

21 Rx is More Often Subject to s in Plans Proportion of Plans Subjecting Rx to 3% 11% 38% 24% 24% No for Rx All Rx Subject to All Brand Subject to Some Brand Subject to Only Specialty Subject to Proportion of Plans Subjecting Rx to ** 2% 1% 23% 57% 17% 21 *Data is for both combined and separate Rx deductibles **Two bronze plans do not fit into the categories highlighted above, because they subject generic and preferred brand Rx to the deductible but exempt specialty Rx

22 Dollars Average Combined s Nearly Twice as High in Plans $7,000 $6,000 $5,000 $5,517 $4,808 $5,435 $5,785 $5,215 $4,000 $3,000 $2,000 $1,000 $2,098 $2,301 $2,163 $2,535 $2,391 $0 No for Rx All Rx Subject to All Brand Subject to Some Brand Subject to Only Specialty Subject to 22

23 Dollars Median Combined s Nearly Twice as High in Plans $7,000 $6,000 $5,000 $6,000 $5,000 $5,600 $5,750 $5,500 $4,000 $3,000 $2,000 $2,000 $2,000 $2,000 $2,450 $2,125 $1,000 $0 No for Rx All Rx Subject to All Brand Subject to Some Brand Subject to Only Specialty Subject to 23

24 Dollars Average Separate Rx s $1,400 $1,305 $1,200 $1,000 $910 $930 $1,050 $800 $600 $400 $442 $ $200 $0 All Rx Subject to All Brand Subject to No bronze plans Some Brand Subject to o 266 plans list a separate Rx deductible but do not subject any Rx to the deductible. In most cases the deductible is $0, however 17 plans list a separate Rx deductible with the average being $20. o 32 plans list a separate Rx deductible but do not subject any Rx to the deductible. In most cases the deductible is $0, however 6 plans list a separate Rx deductible with the average being $55. No bronze plans Only Specialty Subject to

25 Dollars Median Separate Rx s $1,200 $1,000 $1,000 $1,000 $1,000 $800 $750 $600 $400 $400 $500 $200 $0 All Rx Subject to All Brand Subject to No bronze plans Some Brand Subject to No bronze plans Only Specialty Subject to 25 o 266 plans list a separate Rx deductible but do not subject any Rx to the deductible. In most cases the deductible is $0, however 17 plans list a separate Rx deductible greater than $0. o 32 plans list a separate Rx deductible but do not subject any Rx to the deductible. In most cases the deductible is $0, however 6 plans list a separate Rx deductible greater than $0.

26 Percent of Plans that Subject Rx and Other Services to the 77% 82% 75% 89% 68% 72% 43% 46% Primary Care Specialist Care Emergency Room Inpatient Hospital Sn=749 Bn= *Percentages are out of those plans that subject Rx to the deductible **Sn: total number of plans that subject Rx to the deductible ***Bn: total number of plans that subject Rx to the deductible

27 About One-Third of Plans Have a within $500 of Out-of-Pocket Maximum Proportion of Plans with within $500 of OOP Maximum 1056 Total Plans 372 Plans 35.23% 64.77% 684 Plans 27 not within $500 of OOP Maximum within $500 of OOP Maximum

28 Average s: Non-Standardized Benefit States Most Plans Subject Rx to 29% 23% Nearly All Plans Subject Rx to 8% 0.3% Average s Higher in Plans $2,275 $4,986 48% 91.7% $470 $956 Combined Separate Rx No for Rx Combined for Medical and Rx Separate Rx 28 *Combined deductible: A combined deductible means both medical and drug charges contribute to a total plan-level deductible **Separate Rx deductible: A separate Rx deductible means that drug charges contribute to a separate plan-level deductible

29 OUT-OF-POCKET MAXIMUM

30 Nearly All and Plans Have a Combined Out-of-Pocket Maximum Proportion of Plans with Combined vs. Separate Rx OOP Maximum Sn = 1204 Average: $1,503 4% Proportion of Plans with Combined vs. Separate Rx OOP Maximum Bn = 1056 Average: $2, % 96% Average: $5, % Average: $6,291 Combined OOP Maximum Separate Rx OOP Maximum 30 *Sn: total number of unique plans **Bn: total number of unique plans

31 Nearly All Non-Standardized and Plans Have a Combined Out-of-Pocket Maximum Proportion of Plans with Combined vs. Separate Rx OOP Maximum Proportion of Plans with Combined vs. Separate Rx OOP Maximum Average: $1,503 4% Average: $2, % 96% Average: $5, % Average: $6,286 Combined OOP Maximum Separate Rx OOP Maximum 31

32 COST-SHARING

33 Percent of Plans with Coinsurance by Tier 69% 61% 36% 41% 44% 25% 24% 11% Generic Sn=132 / Bn=260 Preferred Brand Sn=286 / Bn=381 Non-Preferred Brand Sn=486 / Bn=459 Specialty Sn=811 / Bn= *Cost sharing patterns may differ if service is subject to a deductible **Sn: total number of plans that charge coinsurance ***Bn: total number of plans that charge coinsurance

34 Average Cost Sharing for Each Prescription Drug Tier Average Copays Average Coinsurance $98 $84 $159 $157 $80 32% 28% 31% 37% 25% 41% 39% 38% 33% 35% 32% $58 $47 $52 16% $13 $18 $10 $29 Generic Preferred Brand Non-Preferred Brand Specialty Generic Preferred Brand Non-Preferred Brand Specialty Employer Average 34 *Cost sharing patterns may differ if service is subject to a deductible ESI Cost Sharing Source: Kaiser Family Foundation, 2013

35 Percent of Plans with Coinsurance Greater Than or Equal to 40 Percent 60% 62% 70% 45% 47% 31% 29% 25% Generic Sn=132 / Bn=260 Preferred Brand Sn=286 / Bn=381 Non-Preferred Brand Sn=486 / Bn=459 Specialty Sn=811 / Bn= *Percentages are out of those plans that charge coinsurance **Sn: total number of plans that charge coinsurance ***Bn: total number of plans that charge coinsurance

36 Of Plans That Charge Copay, Percent That Subject Tier to the 77% 78% 62% 33% 43% 48% 36% 15% Generic Sn=973 / Bn=534 Preferred Brand Sn=860 / Bn=396 Non-Preferred Brand Sn=632 / Bn=306 Specialty Sn=272 / Bn=99 36 *Percentages are out of those plans that charge copays **Sn: total number of plans that charge copays ***Bn: total number of plans that charge copays

37 Of Plans That Charge Coinsurance, Percent That Subject Tier to the 90% 96% 94% 93% 91% 77% 73% 67% Generic Sn=132 / Bn=260 Preferred Brand Sn=286 / Bn=381 Non-Preferred Brand Sn=486 / Bn=459 Specialty Sn=811 / Bn= *Percentages are out of those plans that charge coinsurance **Sn: total number of plans that charge coinsurance ***Bn: total number of plans that charge coinsurance

38 Percent of Plans That Subject Rx Tier to the 85% 87% 87% 54% 49% 61% 64% 24% Generic Sn=1105 / Bn=794 Preferred Brand Sn=1146 / Bn=777 Non-Preferred Brand Sn=1118 / Bn=765 Specialty Sn=1083 / Bn= *Percentages are out of those plans with cost sharing (copay and/or coinsurance) **Sn: total number of plans with copay and/or coinsurance ***Bn: total number of plans with copay and/or coinsurance

39 Average Copay and Coinsurance Charged After the Average Copays After the Average Coinsurance After the $89 $77 $165 $170 26% 32% 29% 37% 40% 38% 35% 32% $54 $47 $10 $14 Generic Preferred Brand Non-Preferred Brand Specialty Generic Preferred Brand Non-Preferred Brand Specialty 39 *Average charges are only for those plans that subject Rx to the deductible

40 Percent of Plans with Coinsurance Charged After the Greater Than or Equal to 40 Percent 68% 59% 57% 44% 43% 25% 28% 19% Generic Sn=119 / Bn=250 Preferred Brand Sn=193 / Bn=358 Non-Preferred Brand Sn=377 / Bn=429 Specialty Sn=594 / Bn= *Percentages are out of those plans that charge coinsurance after the deductible **Sn: total number of plans that charge coinsurance after the deductible ***Bn: total number of plans that charge coinsurance after the deductible

41 Plans Almost Twice as Likely as to Use Copays for Primary Care Visit Plan PCP Visit Cost Sharing Plan PCP Visit Cost Sharing Average PCP Cost Sharing 7% 21% $31 $38 25% 33% 22% 44% 71% 43% Copayment Coinsurance Copayment Coinsurance No Cost Sharing* 41 *No Cost Sharing: Plans charge $0, 0%, or list no charge as applicable cost sharing for an individual. This generally applies after the deductible has been met

42 Plans Almost Twice as Likely as to Use Copays for Specialist Visits Plan Specialist Visit Cost Sharing 25% 7% Plan Specialist Visit Cost Sharing 23% 32% $57 Average Specialist Cost Sharing $71 34% 25% 70% 48% Copayment Coinsurance Copayment Coinsurance No Cost Sharing* 42 *No Cost Sharing: Plans charge $0, 0%, or list no charge as applicable cost sharing for an individual. This generally applies after the deductible has been met

43 Plans Twice as Likely as to Use Copays for Emergency Room Visits Plan ER Cost Sharing Plan ER Cost Sharing Average ER Cost Sharing $392 35% 6% 26% 30% $300 25% 47% 60% 54% Copayment Coinsurance Copayment Coinsurance No Cost Sharing* 43 *No Cost Sharing: Plans charge $0, 0%, or list no charge as applicable cost sharing for an individual. This generally applies after the deductible has been met

44 Limited Number of Plans Utilize Tiered Provider Cost Sharing Proportion of Plans with Tiered Physician Cost Sharing 1% Proportion of Plans with Tiered Hospital Cost Sharing 1% 99% 99% 44 No Tiered Provider Cost Sharing Tiered Provider Cost Sharing

45 Unique Cost Sharing Plans Features o o Copayment/Coinsurance Combination Example: First 3 illness-related office visits subject to $30 copay per visit; all visits thereafter subject to 20% coinsurance and overall deductible Limited Number of Free or Discounted Visits* Example: First 5 PCP visits free; all visits thereafter subject to $10 copay *Free visits generally are a combination of PCP, specialist and other (e.g., chiropractor, physical therapist) visits o o Waiver of for Limited Number of Visits Example: First 2 specialist visits subject to $75 copay; all visits thereafter subject to $75 copay and overall deductible Visit Limits Example: Practitioner visits (other than PCP/specialist) limited to 15 per year 45

46 Summary The majority of plans have combined deductibles and subject all or some prescription drugs to the deductible. The majority of bronze plans also subject other services such as physician visits to the deductible Majority of plans designate a specialty tier. Some plans, though, state that the cost sharing for the specialty product varies by the drug prescribed (e.g., generic, preferred brand and nonpreferred brand) Cost sharing for prescription drugs does not differ significantly between silver and bronze plans However, individuals enrolled in a silver plan may be eligible for cost sharing reductions Majority of silver and bronze plans charge coinsurance for specialty drugs The average coinsurance for all drug tiers in bronzer plans is over 30 percent Both silver and bronze plans typically charge copayments for primary care physician visits. However, bronze plans tend to charge coinsurance rather than copayments for specialist and ER visits, while silver plans charge copayments 46

47 Notes on Data and Sources 47 o This cost sharing analysis is based on a review of the 1204 unique and 1056 unique qualified health plans in all 50 states and the District of Columbia s insurance Exchanges. The premium analysis is based on a review of 7011 plans and 5869 plans in all 50 states and the District of Columbia s insurance exchanges. It was prepared for PhRMA and its member companies based on data available through state and federal governmentsponsored exchange websites as of 1/1/2014. For state-based exchanges (SBEs), Breakaway obtained benefit design and cost sharing data from state exchange websites. If information was not available through the state exchange website, Breakaway obtained the data directly from summaries of benefits coverage (SBCs) posted on the insurance carriers websites. If a carrier did not post the SBC for a plan(s), Breakaway used other information posted by the carrier. Where information in the SBC conflicted with other information posted by the carrier, Breakaway utilized the information provided in the SBC. For federally-facilitated (FFE) and partnership exchanges, Breakaway obtained premium and cost sharing information from the individual market landscape file posted by the Centers for Medicare and Medicaid Services (CMS Landscape File). Where insurance premiums were not available through the state exchange website or carrier website, Breakaway utilized premium data posted on consumer finance website, ValuePenguin.com. When the cost sharing provided on an exchange or carrier website was incomplete or unclear, Breakaway made an effort to obtain the information by contacting the carrier directly. If the carrier was unable to clarify or provide the information, the data was not included in the analysis.

48 Research Methodology 48 Unless otherwise indicated, all premium amounts are for a single individual age 27 or age 50. The premiums and cost sharing figures in this analysis do not reflect the premium credits and cost sharing reductions available to low income individuals. The cost sharing analysis is limited to in-network services. For plans utilizing multiple cost sharing tiers for physicians and/or other providers, data for the first tier was used in this analysis. For plans providing a limited number of free or discounted provider visits, cost sharing that applies after exhaustion of the free or discounted visits was used in this analysis. Because the CMS Landscape File captures data only for four drug tiers, this analysis does not include cost sharing for any designations beyond the fourth tier. In accordance with PhRMA s specifications, and unless otherwise noted, this analysis: Examines premiums and cost sharing without differentiating between plans based on whether prescription drugs and/or other benefits are subject to the deductible. Considers plans that subject specific prescription drug categories to deductible but specify a $0 deductible as not imposing a deductible. Analyses based on different specifications may vary from these results.

49 Questions and Contact Information Dean Rosen President & CEO Margaret Nowak Director of Research Gina Boscarino Sr. Director of Policy

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