Cost-Sharing Subsidies in Federal Marketplace Plans

Cost-Sharing Subsidies in Federal Marketplace Plans

Medical Deductibles

Percent of Plans Where Medical Deductible is Combined With or Separate from Prescription Drug Deductible

55% 55% 55% 55%

45% 45% 45% 45%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Silver CSR73 CSR87 CSR94

Separate

Combined

NOTES: CSR73 refers to a reduced cost-sharing plan with an actuarial value of 73%. CSR87 and CSR94 have actuarial values of 87% and 94%, respectively. SOURCE: Kaiser Family Foundation analysis of Marketplace plans in the 37 states with Federally Facilitated or Partnership exchanges in 2015 (including New Mexico, Oregon, and Nevada). Data are from Healthcare.gov Health plan information for individuals and families available here: https://www.healthcare.gov/health-plan-information/

https://www.healthcare.gov/health-plan-information/





Average Medical Deductible In Plans with Combined Medical and Prescription Drug Deductible

$2,556

$2,077

$737

$229

$0

$500

$1,000

$1,500

$2,000

$2,500

$3,000








Average Medical Deductible In Plans with Separate Medical and Prescription Drug Deductibles

$3,453

$2,763

$659

$159

$0

$500

$1,000

$1,500

$2,000

$2,500

$3,000

$3,500

$4,000








Drug Deductibles

Average Prescription Drug Deductible In Plans with Separate Medical and Prescription Drug Deductible

$335

$224

$79

$37

$0

$50

$100

$150

$200

$250

$300

$350

$400








Out-of-Pocket Limits

Average Out-Of-Pocket Limit In Plans with Combined Limit for Medical and Prescription Drug Cost Sharing

$5,826

$4,624

$1,692

$881

$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

$7,000








Inpatient Facility Cost Sharing

Share of Plans by Type of Inpatient Facility Cost Sharing

<1% <1% <1% 1% 15% 17%

25% 26%

13% 13%

13% 12%

61% 59% 55% 54%

12% 11% 7% 6%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Copay & Coinsurance

Coinsurance

Copayment

No Charge afterDeductibleNo Charge







Average Copayments for Inpatient Facility Services (includes plans with both copayments and coinsurance)

$936 $902

$506

$317

$511 $489

$332

$245

$0

$100

$200

$300

$400

$500

$600

$700

$800

$900

$1,000


Per Day

Per Stay







Average Inpatient Facility Coinsurance Rate (includes plans with both coinsurance and copayments)

28% 27%

19%

16%

0%

5%

10%

15%

20%

25%

30%








Inpatient Physician Services

Share of Plans by Type of Cost Sharing for Inpatient Physician Services

3% 4% 4% 7%

21% 24% 31%

32% <1%

<1%

<1% <1%

75% 72% 65% 61%

<1% <1% <1% <1%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Copay & Coinsurance

Coinsurance

Copayment

No Charge after Deductible

No Charge







Average Copayments for Inpatient Physician Services

$177 $176

$133 $125

$0

$20

$40

$60

$80

$100

$120

$140

$160

$180

$200








Average Coinsurance Rate For Inpatient Physician Services (includes plans with both coinsurance and copayments)

28% 27%

19%

16%

0%

5%

10%

15%

20%

25%

30%








Primary and Specialist Physician Cost Sharing

Share of Plans by Type of Cost Sharing for Primary Care Physician Visits (deductible may apply first)

1% 1% 3%

13% 10% 11% 13%

13%

73% 73% 71%

61%

13% 13% 10% 10%

3% 3% 3% 3%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Copay & Coinsurance

Coinsurance

Copayment

No Charge afterDeductible

No Charge







Average Copayments for Primary Care Physician Visits

$28

$23

$17

$14

$0

$5

$10

$15

$20

$25

$30








Average Coinsurance Rates for Primary Care Physician Visits

26%

25%

24%

22%

20%

21%

22%

23%

24%

25%

26%








Share of Plans by Type of Cost Sharing for Specialist Physician Visits (deductible may apply first)

1% 2% 11% 12% 14% 14%

70% 69% 68% 68%

18% 17% 15% 15%

2% 1% 1% 1%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Silver CSR73 CSR87 SR94

Copay & Coinsurance

Coinsurance

Copayment


No Charge







Average Copayments for Specialist Physician Visits

$56

$51

$35

$25

$0

$10

$20

$30

$40

$50

$60








Average Coinsurance Rates for Specialist Physician Visits

26% 26%

24%

21%

0%

5%

10%

15%

20%

25%

30%








Prescription Drugs

Share of Plans by Type of Cost Sharing for Generic Prescription Plans with Combined Medical and Prescription Drug Deductible

<1% 1% 2% 3% 17% 18% 21% 21%

65% 64% 63% 62%

18% 17% 13% 13%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Coinsurance

Copayment


No Charge







Share of Plans by Type of Cost Sharing for Generic Prescription Plans with Separate Medical and Prescription Drug Deductible

17% 17% 17% 19%

1% 1% 1% 1%

82% 82% 82% 80%

<1% <1% <1% <1%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Silver SR73 CR87 CSR94

Coinsurance

Copayment

No Charge After Deductible

No Charge







Average Copayment for Generic Drugs

$13

$11

$8

$7

$0

$2

$4

$6

$8

$10

$12

$14








Average Coinsurance Rates for Generic Drugs

29% 28%

26%

23%

0%

5%

10%

15%

20%

25%

30%








Share of Plans by Type of Cost Sharing for Preferred Prescriptions Plans with Combined Medical and Prescription Drug Deductible

17% 17% 21% 21%

58% 58% 58% 58%

26% 25% 22% 21%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Silver CSR73 SR87 CSR94

Coinsurance

Copayment








Share of Plans by Type of Cost Sharing for Preferred Prescriptions Plans with Separate Medical and Prescription Drug Deductible

94% 94% 94% 94%

6% 6% 6% 6%

90%

91%

92%

93%

94%

95%

96%

97%

98%

99%

100%

Silver CSR73 SR87 SR94

Coinsurance

Copayment







Average Copayment for Preferred Drugs

$47

$44

$34

$28

$0

$5

$10

$15

$20

$25

$30

$35

$40

$45

$50








Average Coinsurance Rates for Preferred Drugs

30% 30%

27%

24%

0%

5%

10%

15%

20%

25%

30%

35%








Share of Plans by Type of Cost Sharing for Non-Preferred Prescriptions Plans with Combined Medical and Prescription Drug Deductible

20% 20% 24% 24%

40% 40% 40% 40%

40% 40% 36% 36%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Coinsurance

Copayment








Share of Plans by Type of Cost Sharing for Non-Preferred Prescriptions Plans with Separate Medical and Prescription Drug Deductible

75% 75% 75% 75%

25% 25% 25% 25%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Coinsurance

Copayment







Average Copayment for Non-Preferred Drugs

$85 $81

$67

$57

$0

$10

$20

$30

$40

$50

$60

$70

$80

$90








Average Coinsurance Rates for Non-Preferred Drugs

37% 36% 34%

31%

0%

5%

10%

15%

20%

25%

30%

35%

40%








Share of Plans by Type of Cost Sharing for Specialty Prescriptions Plans with Combined Medical and Prescription Drug Deductible

22% 22% 35% 35%

9% 9%

9% 9%

68% 68% 55% 55%

1% 1% 1% 1%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Copay andCoinsurance

Coinsurance

Copayment








Share of Plans by Type of Cost Sharing for Specialty Prescriptions Plans with Separate Medical and Prescription Drug Deductible

33% 33% 33% 33%

67% 67% 67% 67%

<1% <1% <1% <1%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Copay &Coinsurance

Coinsurance

Copayment







Average Copayment for Specialty Drugs

$179 $174

$156

$120

$0

$20

$40

$60

$80

$100

$120

$140

$160

$180

$200








Average Coinsurance Rates for Specialty Drugs

36% 35%

31%

27%

0%

5%

10%

15%

20%

25%

30%

35%

40%








Emergency Room Cost Sharing

Share of Plans by Type of Emergency Room Cost Sharing

1% 8% 9% 11% 12%

46% 46% 51% 49%

28% 28% 26% 25%

18% 17% 12% 12%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Copay &Coinsurance

Coinsurance

Copayment


No Charge







Average Emergency Room Copayments (includes plans with both copayments and coinsurance)

$318

$270

$196

$168

$0

$50

$100

$150

$200

$250

$300

$350








Average Emergency Room Coinsurance Rate (includes plans with both coinsurance and copayments)

28% 27%

21%

19%

0%

5%

10%

15%

20%

25%

30%








Cost-Sharing Subsidies in Federal Marketplace Plans

Health & Medicine

actuarial values

silver csr73 csr87 csr94notes

prescription drug cost

average medical deductible

reduced cost

health plan information

prescription drug deductibles

families available