ICYMI: Higher out-of-pocket costs in health insurance exchange plans compared to employer plans for patients managing chronic conditions

Rachel Licata   |     October 7, 2015   |   SHARE THIS

A recent study published in Health Affairs took a look at estimated out-of-pocket expenses for individuals living with chronic conditions if they switched from average employer-sponsored plans to a silver health insurance exchange plan. The study focused on prescription drug spending and looked at the potential impact of higher cost sharing on medicines and spending on other health care services.

Highlights from the study include:

  • Among patients with one chronic condition, the study found switching from the average employer-sponsored plan to a typical silver plan – the most popular in the exchanges – would double out-of-pocket expenses.
  • One reason for higher out-of-pocket expenses is the use of a combined medical and drug deductible in exchange plans. (See our previous research here on use of combined deductibles.) This means patients are faced with meeting their deductible before any coverage kicks in.
  • Actuarial value (AV) – or the percent of total average costs a plan covers – in silver plans is lower than that of employer plans.
  • Researchers found increases out-of-pocket spending would reduce prescription fills and increase spending on other medical services. Specifically, among patients with four or more chronic conditions, “Total prescription spending would go down by about $384 annually, but the reduction in adherence would lead to a rise in other expenditures of $682 per year – a net increase of $298.”

Catalyst_Promo4These findings are a reminder about the importance in estimating out-of-pocket costs when selecting a plan, particularly among individuals are living with one or more chronic conditions.

Whether you’ve been choosing an annual health plan for years or have coverage for the first time, it can be hard to know what your plan covers and how to prepare for out-of-pocket costs. That’s why we created AccessBetterCoverage.org to help cut through the confusing jargon to better understand coverage options and the questions to ask to choose the best plan for you and your family.

Rachel Licata

Rachel Licata Rachel is a senior director of policy and research at PhRMA focusing on the Affordable Care Act and other public programs. Prior to joining PhRMA she worked at the Kaiser Family Foundation and the Department of Health and Human Services. Rachel enjoys taking yoga classes and exploring the local cuisine of the Maryland suburbs.

Topics: Access, Affordable Care Act, Access Better Coverage

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