Cost-Sharing Subsidies in Federal Marketplace Plans

Cost-Sharing Subsidies in
Federal Marketplace Plans

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/

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

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

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 after
Deductible
No 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%

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
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 after
Deductible
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 after
Deductible
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%

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
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
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
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
No Charge after
Deductible

Share of Plans by Type of Cost Sharing for Non-Preferred Prescriptions
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
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 and
Coinsurance
Coinsurance
Copayment
No Charge after
Deductible

Share of Plans by Type of Cost Sharing for Specialty Prescriptions
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%

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 after
Deductible
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
28% 27%
21%
19%
0%
5%
10%
15%
20%
25%
30%

Cost-Sharing Subsidies in Federal Marketplace Plans

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