With the enrollment season for the second year of Affordable Care Act health plans commenced, consumers who purchase their own health insurance are again comparing deductibles and other healthcare out-of-pocket costs. The first enrollment year for the Affordable Care Act brought with it average deductibles for bronze, silver, and gold plans that surpassed the amounts needed to qualify them as high deductible health plans.1 The average deductible for the platinum plan was alone among the new “metal plans” to fall under the threshold for a high deductible health plan.2
High deductible costs have attracted significant consumer and media attention for Affordable Care Act plans with unflattering comparisons made to the average deductibles observed for employer-sponsored health plans.3 HealthPocket examined government data on 2015 Affordable Care Act health plans available for private purchase (i.e. non-employer coverage) and found that deductibles remained high for bronze, silver, and gold plans though both gold and platinum plans had both individual and family deductible averages decrease from 2014 levels.
|COST-SHARING CATEGORY||AVERAGE FOR A BRONZE PLAN|
|Deductible for an individual enrollee||$5,181|
|Deductible for a family||$10,545|
|Doctor Visit||34% of doctor visit expense charged as coinsurance fee. Coinsurance was the most common form of cost-sharing for doctor visits among 2015 Bronze Plans|
|Specialist Visit||34% of specialist visit expense charged as coinsurance fee. Coinsurance was the most common form of cost-sharing for specialist visits among 2015 Bronze Plans|
|Annual cap on out-of-pocket costs for an individual||$6,373|
|Annual cap on out-of-pocket costs for a family||$12,749|
Commentary – Bronze plans are the most commonly purchased Affordable Care Act plan by consumers who shop off-exchange.4 Since premium subsidies are available on-exchange, off-exchange shoppers are assumed to represent a population that is largely ineligible for those subsidies. The average bronze plan deductible for 2015 is $5,181, up from $5,081 in 2014.5 The average 2015 bronze plan deductible for an individual is 326% higher than the average deductible amount documented for employer-sponsored health plans (deductibles in employer-sponsored health insurance were $1,217 on average for individual coverage according to the Kaiser Family Foundation’s 2014 Employer Health Benefits Survey).6
Bronze plans were the only one of the four Affordable Care Act metal plans that had coinsurance fees as the most common7 form of out-of-pocket costs for doctor and specialist visits. The remaining metal plans used co-payments most frequently for doctor and specialist visit cost-sharing. Coinsurance fees are a form of enrollee cost-sharing where a percentage of the cost of a medical service is charged to the enrollee. For both doctor visits and specialist visits, bronze plans charged coinsurance fees most often and the amount was 34% of the visit price.
At $6,373 for individuals and $12,749 for families, the average caps on annual out-of-pocket costs for covered medical services delivered in-network were similar to 2014 levels.
|COST-SHARING CATEGORY||AVERAGE FOR A SILVER PLAN|
|Deductible for an individual enrollee||$2,927|
|Deductible for a family||$6,010|
|Doctor Visit||$29. Flat fee copayment was the most common form of cost-sharing for doctor visits among 2015 Silver Plans|
|Specialist Visit||$57. Flat fee copayment was the most common form of cost-sharing for specialist visits among 2015 Silver Plans|
|Annual cap on out-of-pocket costs for an individual||$5,775|
|Annual cap on out-of-pocket costs for a family||$11,555|
Commentary – Silver plans are the most frequently purchased metal plan type on government health insurance exchanges.8 For those people ineligible for cost-sharing subsidies, the average silver plan deductible amount was very similar in 2015 to the levels observed for 2014, the individual deductible being approximately 1% higher in 2015 and the family deductible approximately 1% lower in 2015. Caps on out-of-pocket costs were also within 1% of 2014 averages.
The average copayment for doctor visits in 2015 decreased by 9% to $29 while the average cost of a specialist visit rose $1 to $57.
|COST-SHARING CATEGORY||AVERAGE FOR A GOLD PLAN|
|Deductible for an individual enrollee||$1,198|
|Deductible for a family||$2,626|
|Doctor Visit||$23. Flat fee copayment was the most common form of cost-sharing for doctor visits among 2015 Gold Plans|
|Specialist Visit||$45. Flat fee copayment was the most common form of cost-sharing for specialist visits among 2015 Gold Plans|
|Annual cap on out-of-pocket costs for an individual||$4,298|
|Annual cap on out-of-pocket costs for a family||$8,986|
Commentary – At $1,198, the average deductible amount for individuals is below both the 2014 average of $1,277 and the 2015 definition of a high deductible plan for individuals ($1,300).9 The average gold plan deductible for families, however, remains in the high deductible health plan range at $2,626.10 In 2014, the average family deductible was even higher for gold plans at $2,846.
The average cost of doctor and specialist visits declined by $1 in 2015 to $23 and $45 respectively.
|COST-SHARING CATEGORY||AVERAGE FOR A PLATINUM PLAN|
|Deductible for an individual enrollee||$243|
|Deductible for a family||$489|
|Doctor Visit||$18. Flat fee copayment was the most common form of cost-sharing for doctor visits among 2015 Platinum Plans|
|Specialist Visit||$29. Flat fee copayment was the most common form of cost-sharing for specialist visits among 2015 Platinum Plans|
|Annual cap on out-of-pocket costs for an individual||$1,971|
|Annual cap on out-of-pocket costs for a family||$3,942|
Commentary – Platinum plans evidenced the greatest improvement in average deductible amounts compared to 2014. The average individual and family deductibles are 30% lower than the averages documented for 2014.11 In contrast, the annual cap on out-of-pocket costs for covered medical services delivered in-network increased by 6% for both individuals and families in 2015.12
The average cost of doctor visits was up 13% to $18 in 2015 while specialist visits declined 3% to $29.
Some Affordable Care Act plans had a separate deductible that exclusively applied to covered prescription drugs. A smaller drug deductible than a overall medical deductible could allow insurance cost-sharing to begin earlier in the case of medications. With respect to individuals, HealthPocket found the following:
|Bronze Plans||Silver Plans||Gold Plans||Platinum Plans|
|% of Plans with a Separate Drug Deductible||5%||40%||52%||61%|
|Average Drug Deductible Cost for an Individual When Applicable||$435||$274||$123||$64|
These secondary deductibles for covered medications become more prevalent as the cost of the metal tier increases. Only 5% of entry-level bronze plans have separate drug deductibles while 61% of top-tier platinum plans have separate drug deductibles. Unsurprisingly, for those plans that do have separate deductibles, the average amount of the deductible decreases as the metal tier rises. Bronze plans with separate deductibles for medications average $435 for this deductible category while platinum plans averaged only $64.
2015 marks another year where unsubsidized deductibles average over $1,000 for three of the four Affordable Care Act plan types. Gold and Platinum plans evidenced deductible improvements as compared to 2014 while bronze and silver plans were slightly higher.
Consumers should make note that deductible averages characterize a range of deductible amounts from lower to higher. Accordingly, for those consumers who expect to use healthcare moderately to frequently, careful attention should be paid to health plan cost-sharing before enrollment. In many cases, out-of-pocket copayment and coinsurance fees for physician visits apply after a deductible amount has been satisfied, meaning that the consumer would pay the full cost of the visit during the deductible period.
Those consumers making 250% or less of the 2014 Federal Poverty Level are eligible for cost-sharing subsidies that reduce deductibles, co-payments, and coinsurance fees.13 These cost-sharing reductions are only available on silver plans for those who qualify.14
Healthier consumers who expect to use healthcare infrequently should focus less on cost-sharing and more on premium expense and the quality of in-network healthcare providers in the event that a serious medical condition occurs.
Out-of-pocket costs for 2015 Affordable Care Act health plans was based on multiple Qualified Health Plan (QHP) Landscape files for government marketplaces (2015_QHP_Landscape_Individual_Market_Medical, 2015_QHP_Landscape_NM_Individual_Market_Medical, 2015_QHP_Landscape_NV_Individual_Market_Medical, and 2015_QHP_Landscape_OR_Individual_Market_Medical). Bronze, silver, gold, and platinum health plan data was used, covering multiple rating regions within the states included in the landscape file. Catastrophic plans, while Affordable Care Act health plans, were not included within the scope of this study due to their special eligibility requirements. Premiums do not include any applicable government subsidies. The QHP Landscape files were downloaded by HealthPocket from the Centers for Medicare & Medicaid Services November 14, 2014.
All plans investigated in this study belong to the individual & family insurance market. Medicare, Medicaid, short-term health insurance, and group health insurance plans were not analyzed as part of this study.
Industry standard rounding methods were utilized.
No weighting by health plan enrollment was performed.
This preview was written by Kev Coleman, Head of Research & Data at HealthPocket. Correspondence regarding this data can be directed to Mr. Coleman at email@example.com.
1 In calendar year 2014, a high deductible health plan was defined as “a health plan with an annual deductible that is not less than $1,250 for self-only coverage or $2,500 for family coverage.” http://www.irs.gov/pub/irs-drop/rp-13-25.pdf In 2014, the average deductible for 2014 bronze plans was $5,081 individual/$10,386 family, the average deductible for 2014 silver plans was $2,907 individual/$6,078 family, and the average deductible for 2014 gold plans was $1,277 individual/$2,846 family. Kev Coleman and Jesse Geneson. “Deductibles, Out-Of-Pocket Costs, and the Affordable Care Act.” HealthPocket.com (December 12, 2013). http://www.healthpocket.com/healthcare-research/infostat/2014-obamacare-deductible-out-of-pocket-costs
2 While a 2014 high deductible health plan must have a deductible at least $1,250 for an individual and $2,500 for a family, the average deductible for platinum plans in 2014 was $347 individual/$698 family. Coleman, Geneson. “Deductibles, Out-Of-Pocket Costs, and the Affordable Care Act.”
3 Robert Pear. “On Health Exchanges, Premiums May Be Low, but Other Costs Can Be High” New York Times. (December 9, 2013). http://www.nytimes.com/2013/12/09/us/on-health-exchanges-premiums-may-be-low-but-other-costs-can-be-high.html. Last accessed November 19, 2014.
4 See online broker eHealth’s statistics on their off-exchange sales. “Health Insurance Price Index Report for Open Enrollment and Q1 2014” eHealth. (May, 2014). p.4. http://news.ehealthinsurance.com/_ir/68/20144/eHealth%20Health%20Insurance%20Price%20Index%20Report%20for%20Open%20Enrollment%20and%20Q1%202014.pdf. Last accessed November 19, 2014.
5 Coleman, Geneson. “Deductibles, Out-Of-Pocket Costs, and the Affordable Care Act.”
6 Kaiser Family Foundation and Health Research & Education Trust. “Employer Health Benefits - 2014 Annual Survey.” Kaiser Family Foundation. (September 10, 2014). p.125. http://files.kff.org/attachment/2014-employer-health-benefits-survey-full-report. Last accessed November 19, 2014.
7 As compared to copayments or no cost-sharing. Instances where copayments were used in stage of coverage (e.g. deductible period) and coinsurance fees were used in a different period of coverage (e.g. post-deducible) were excluded though they were not more common than coinsurance fees alone with respect to bronze plans.
8 A post-annual enrollment period report for the 2014 plan year reported that “65 percent of the persons who have selected a Marketplace plan have selected a Silver plan.” “HEALTH INSURANCE MARKETPLACE: SUMMARY ENROLLMENT REPORT FOR THE INITIAL ANNUAL OPEN ENROLLMENT PERIOD.” Department of Health and Human Services. (May 1, 2014). http://aspe.hhs.gov/sites/default/files/pdf/76876/ib_2014Apr_enrollment.pdf Last accessed November 19, 2014.
10 The minimum family deductible amount to qualify as a high deductible plan is $2,600 in 2015. http://www.irs.gov/pub/irs-drop/rp-14-30.pdf
11 See Coleman, Geneson. “Deductibles, Out-Of-Pocket Costs, and the Affordable Care Act.”
12 The annual cap on out-of-pocket costs for platinum plans in 2014 was $1,971 for individuals and $3,942 for families. See Coleman, Geneson. “Deductibles, Out-Of-Pocket Costs, and the Affordable Care Act.”
HealthPocket is a free information source designed to help consumers find medical coverage. Whether you are looking for Medicare, Medicaid or an individual health insurance plan, we will help you find the right healthcare option and save on your out of pocket healthcare costs. We receive our data from government, non-profit and private sources, and you should confirm key provisions of your coverage with your selected health plan. If you select a plan presented on our site, you will be directed (via a click or a call) to one of our partners who can help you with your application. Our website is not a health insurance agency and not affiliated with and does not represent or endorse any health plan. HealthPocket, Inc. is a wholly owned subsidiary of Health Plan Intermediaries Holdings LLC (NASDAQ: HIIQ)