Unbiased Analysis of Today's Healthcare Issues

Are plans in the health insurance exchanges affordable?

Written By: Jason Shafrin - Sep• 26•13

In terms of the level of premiums, the answer is yes, these plans are relatively affordable.  The Wall Street Journal reports that:

Across the country, the average premium for a 27-year-old nonsmoker, regardless of gender, will start at $163 a month for the lowest-cost “bronze” plan; $203 for the “silver” plan, which provides more benefits than bronze; and $240 for the more-comprehensive “gold” plan.

Lower premiums comes at cost for consumers: more cost-sharing.  Avalere describes the common cost sharing practices among 22 health plans included within 6 health insurance exchanges.


For non-subsidized Silver plans analyzed, the average deductible is $2,550 for individual coverage, ranging from a low of $1,500 to a high of $5,000. By comparison, in 2013, 78 percent of single enrollees in employer-sponsored coverage had a deductible with an average value of $1,135 per year-—less than half the average Silver deductible in exchange plans. Bronze exchange plans had even higher deductibles with an overall average of $5,150, ranging from $2,000 to $6,350 among plans analyzed.

Drug Coinsurance

Approximately 90 percent of Bronze plans will rely on coinsurance, which is calculated based as a percentage of drug costs rather than fixed dollar co-payments, for higher pharmacy tiers.  Based on the rate filings, average coinsurance rates for drugs in Tier 3 and Tier 4 are approximately 40 percent. Interestingly for Silver plans—just like for Bronze plans— average coinsurance is 40 percent for Tier 3 and Tier 4. The biggest difference is that several Silver exchange plans utilize copays (as opposed to coinsurance) for Tiers 3 and 4 in which the averages were $70 for Tier 3 and $270 for Tier 4. By comparison to today’s employer-sponsored market, only 29 percent of those with employer coverage have coinsurance on their highest pharmacy tier.

Primary Care Visits

Further analysis of exchange benefit designs found that the average cost for a primary care provider (PCP) visit in Silver Plans is a $30 copay, though this copay ranges from $5 to $50 throughout the plans. Several Silver plans are charging coinsurance rates for PCP visits ranging from 10 percent to 20 percent.

In addition, the New York Times reports that consumers who buy these plans will have fewer choices of physicians. “Insurers are driving down premiums by restricting the number of providers who will treat patients in their new health plans.” Further, consumers who seek care from providers outside their network may face very high out-of-pocket costs.

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