In addition, people who earn 250 percent of the federal poverty level or less will also have their maximum out-of-pocket spending capped at lower levels than will be the case for others who buy plans on the exchange. In 2014, the out-of-pocket limits for most plans will be $6,350 for an individual and $12,700 for a family. But people who qualify for cost-sharing subsidies will see their maximum out-of-pocket spending capped at $2,250 or $4,500 for single or family coverage, respectively, if their incomes are less than 200 percent of the poverty level, and $5,200 or $10,400 if their incomes are between 200 and 250 percent of poverty.
Insurers have some flexibility in how they structure their plans to meet cost-sharing reductions. But in states that will require plans to standardize deductibles, copayments and coinsurance amounts, it's possible to see how out-of-pocket costs may vary.
In California, for example, a standard silver plan will have a $2,000 deductible, a $6,400 maximum out-of-pocket limit and a $45 copayment for a primary care office visit. Someone whose income is between 150 and 200 of the poverty level, on the other hand, will have a silver plan with a $500 deductible, a $2,250 maximum out-of-pocket limit and $15 copays for primary care doctor visits.
Healthy people might be inclined to go with an exchange bronze plan or the catastrophic plan (a high-deductible plan available only to people under age 30 that will have lower premiums than a silver plan), figuring they won’t need the cost-sharing assistance.
"It's an individual calculation," says Jennifer Tolbert, director of state health reform at the Kaiser Family Foundation. (KHN is an editorially independent program of the foundation.)
However, she says, services that aren’t preventive in nature may be subject to a much higher deductible than in a silver plan--$5,000 in the case of the California bronze plan--and could result in significant cost sharing.
"And remember, those people are going to be getting pretty significant premium tax credits for the silver plan, which will bring the cost of premiums down quite a bit," she says.
Consumers should keep in mind, though, the cost-sharing subsidies apply to in-network expenses only. That may become an issue in some plans with limited provider networks.
"In the exchanges, a lot of insurers are going to narrower networks as a way to keep costs down," says Christine Monahan, a senior health policy analyst at Georgetown University’s Center on Health Insurance Reforms. "If you go out of network, you could be subject to higher cost sharing and balance billing."
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Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communications organization not affiliated with Kaiser Permanente.
Mon, Dec 19 2011