Cost Sharing in Marketplace Plans

Cost-Sharing for Plans Offered in Federally Facilitated or Partnership Marketplaces for 2015

Medical and Prescription Drug Deductibles

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/

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

91%

55%

37% 38%

9%

45%

63% 62%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Bronze Silver Gold Platinum

Separate

Combined

http://healthcare.gov/

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






Average Medical Deductible, in Plans with Combined Medical and Prescription Drug Deductibles

$5,328

$2,556

$845

$69 $0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000









Distribution of Medical Deductibles, for all Plans with Combined Medical and Prescription Drug Deductible

2%

11%

39%

47%

5% 9%

41% 38%

6%

42% 45%

11%

96%

4%

0%

20%

40%

60%

80%

100%

120%

$500 or less >$500 - $1500 >1500-$2500 >2500-$4000 >4000-$5500 Over $5500









Distribution of Medical Deductibles, for Bronze Plans with Combined Medical and Prescription Drug Deductible

0%

2%

11%

30%

34%

22%

0%

5%

10%

15%

20%

25%

30%

35%

40%

$2000 or less >$2000 -$2500 >$2500 - $4000 >$4000 - $5000 >$5000 - $6000 Over $6000








Distribution of Medical Deductibles, for Silver Plans with Combined Medical and Prescription Drug Deductibles

4%

9%

41%

38%

7%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

$0 >0 - $1500 >$1500 -$2500 >$2500 - $4000 Over $4000








Distribution of Medical Deductibles, for Gold Plans with Combined Medical and Prescription Drug Deductibles

27%

15%

25%

20%

8%

5%

0%

5%

10%

15%

20%

25%

30%

$0 >0 - $500 >$500-$1000 >$1000 - $1500 >$1500 - $2000 Over $2000








Distribution of Medical Deductibles for Platinum Plans with Combined Medical and Prescription Drug Deductibles

84%

13%

4%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

$0 >0 - $500 Over $500








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

$5,372

$3,453

$1,431

$418

$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000









Distribution of Medical Deductibles, for all Plans with Separate Medical and Prescription Drug Deductible

2% 6%

48%

43%

2% 4%

24%

42%

20%

8%

17%

58%

14% 10%

71%

29%

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

$500 or less >$500 - $1500 >1500-$2500 >2500-$4000 >4000-$5500 Over $5500

Bronze

Silver

Gold

Platinum








Distribution of Medical Deductibles, for Bronze Plans with Separate Medical and Prescription Drug Deductibles

2%

6%

40%

31%

19%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

$2500 or less >$2500 -$4000 >4000 - $5000 >$5000 - $6000 Over $6000








Distribution of Medical Deductibles, for Silver Plans with Separate Medical and Prescription Drug Deductibles

2%

15%

31%

24%

19%

9%

0%

5%

10%

15%

20%

25%

30%

35%

$0 >$0 - $2000 $>2000 -$3000 >$3000 - $4000 >$4000 - $5000 Over $5000








Distribution of Medical Deductibles, for Gold Plans with Separate Medical and Prescription Drug Deductibles

3%

14%

26%

31%

7%

18%

0%

5%

10%

15%

20%

25%

30%

35%

$0 >$0 - $500 >$500-$1000 >$1000 - $1500 >$1500 - $2000 Over $2000








Distribution of Medical Deductibles, for Platinum Plans with Separate Medical and Prescription Drug Deductibles

30%

41%

29%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

$0 >$0 - $500 Over $500







Separate Drug Deductibles


Average Prescription Drug Deductible, for Plans with Separate Medical and Prescription Drug Deductible

$465

$335

$139 $133

$0

$50

$100

$150

$200

$250

$300

$350

$400

$450

$500









Distribution of Prescription Drug Deductibles, for Bronze Plans with Separate Medical and Prescription Drug Deductibles

52%

2%

10%

15%

19%

0%

10%

20%

30%

40%

50%

60%

$0 >$0 - $250 >$250 - $500 >$500 - $1000 Over $1000








Distribution of Prescription Drug Deductibles, for Silver Plans with Separate Medical and Prescription Drug Deductibles

54%

8%

17% 15%

7%

0%

10%

20%

30%

40%

50%

60%

$0 >$0 - $250 >$250 - $500 >$500 - $1000 Over $1000








Distribution of Prescription Drug Deductibles, for Gold Plans with Separate Medical and Prescription Drug Deductibles

61%

20% 19%

0% 0%

10%

20%

30%

40%

50%

60%

70%

$0 >$0 - $250 >$250 - $500 Over $500








Distribution of Prescription Drug Deductibles, for Platinum Plans with Separate Medical and Prescription Drug Deductibles

69%

8%

22%

1%

0%

10%

20%

30%

40%

50%

60%

70%

80%

$0 >$0 - $250 >$250 - $500 Over $500







Inpatient Facility Cost Sharing


Share of Plans by Type of Inpatient Facility Cost Sharing

4%

35%

15% 8%

4%

9%

13%

14% 12%

52%

61% 68% 79%

4% 12% 9%

1%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Copay & Coinsurance

Coinsurance

Copayment

No Charge after Deductible

No Charge















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

$780

$936

$502

$269

$456

$511

$323 $321

$0

$100

$200

$300

$400

$500

$600

$700

$800

$900

$1,000


Per Day

Per Stay








Distribution of Inpatient Facility Copayments

7%

49%

6%

46%

19%

77%

48%

71%

27%

44%

34%

46%

47%

17%

52%

29%

20%

2%

15%

1%

19%

3%

0% 0%

33%

2%

29%

2% 16%

0% 0%

13%

2%

17%

5% 2% 0% 0%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Bronze perday

Bronze perstay

Silver per day Silver per stay Gold per day Gold per stay Platinum perday

Platinum perstay

Over $1000

>$750 - $1000

>$500 - $750

>$250 - $500

$250 or less








Average Inpatient Facility Coinsurance Rate

32%

28%

20% 20%

0%

5%

10%

15%

20%

25%

30%

35%









Distribution of Inpatient Facility Coinsurance Rates

5% 7% 15%

23%

52%

73%

84% 74%

25%

8%

1%

18% 12%

1% 3% 1%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Over 50%

>40%-50%

>30% - 40%

>20% - 30%

20% or less







Inpatient Physicians Cost Sharing


Share of Plans by Type of Cost Sharing for Inpatient Physicians Cost Sharing

1% 3% 5%

16%

41%

21% 14%

5% 1%

57%

75% 80% 79%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Coinsurance

Copayment


No Charage








Average Coinsurance Rates For Inpatient Physician Services

32%

28%

20% 21%

0%

5%

10%

15%

20%

25%

30%

35%









Distribution of Inpatient Physician Coinsurance Rates

7% 7%

17% 21%

50%

74%

82% 77%

25%

8%

1%

18%

12%

1% 3% 1%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Over 50%

>40%-50%

>30% - 40%

>20% - 30%

20% or less







Specialist and Primary Care Physician Office Visits


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

1% 2% 1%

32%

10% 4%

39% 73% 83% 92%

24%

13% 10%

6% 6% 3% 2%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Copay & Coinsurance

Coinsurance

Copayment


No Charage








Average Copayments for Primary Care Physician Visits

$37

$28

$22

$19

$0

$5

$10

$15

$20

$25

$30

$35

$40









Distribution of Copayments for Primary Care Physician Visits

1%

15% 20%

25% 17%

12%

28% 26%

18%

50%

45% 47%

40%

12%

4% 1%

14%

10%

3% 1%

10%

1%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Over $50

>$40 - $50

>$30 - $40

>$20 - $30

>$10 - $20

$10 or less








Average Coinsurance Rates for Primary Care Physician Visits

33%

26%

21% 21%

0%

5%

10%

15%

20%

25%

30%

35%









Distribution of Coinsurance Rates for Primary Care Physician Visits

5%

17% 24%

42% 26%

36%

56% 26%

17%

30%

13%

16%

32%

5%

2% 18%

12% 5%

16%

1%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Over 50%

>40% - 50%

>30% - 40%

>20% - 30%

>10% - 20%

10% or less








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

34%

11% 4% 1%

33%

70% 81% 91%

30%

18% 13%

8% 3% 2% 2%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Copay & Coinsurance

Coinsurance

Copayment









Average Copayments for Specialist Physician Visits

$65

$56

$44

$29

$0

$10

$20

$30

$40

$50

$60

$70









Distribution of Copayments for Specialist Physician Visits

3% 1% 2%

13%

47%

40%

47%

71%

48%

34%

45%

16%

2%

20%

5% 5%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Over $100

>$75 - $100

>$50 - $75

>$25 - $50

>$10 - $25

$10 or less








Average Coinsurance Rates for Specialist Physician Visits

34%

26%

19% 19%

0%

5%

10%

15%

20%

25%

30%

35%

40%









Distribution of Coinsurance Rates for Specialist Physician Visits

5%

16%

28%

52%

25%

34%

56%

22%

18%

31%

11%

13%

31%

6%

2%

0% 20%

14%

4%

13%

1% 0%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Over 50%

>40% - 50%

>30% - 40%

>20% - 30%

>10% - 20%

10% or less







Prescription Drug Cost Sharing


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

5% 1%

21%

46% 48%

38% 28% 25%

34%

12% 18%

22% 28%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Copayment & Coinsurance

Coinsurance

Copayment









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

17% 20%

2%

98%

82% 78%

97%

2% 1% 1% 1%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Coinsurance

Copayment

No Charge








Average Copayment for Generic Drugs

$19

$13

$10

$8

$0

$2

$4

$6

$8

$10

$12

$14

$16

$18

$20









Distribution of Copayment Amounts for Generic Drugs

5% 11%

15%

33%

11%

34%

55%

67%

22%

37%

24%

1%

26%

15%

6%

25%

3% 0%

11%

1%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Over $25

>$20 - $25

>$15 - $20

>$10 - $15

>$5 = $10

$5 or less








Average Coinsurance Rates for Generic Drugs

30% 29%

23%

26%

0%

5%

10%

15%

20%

25%

30%

35%









Distribution of Coinsurance Rates for Generic Drugs

13% 17%

38%

20%

19%

34%

20%

10%

37%

20%

23%

50%

7% 4%

5% 0%

24% 25%

15% 20%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


40% or more

>30% - >50%

>20% - 30%

>10% - 20%

10% or less








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

36%

17%

8%

26% 58%

69% 91%

38%

26% 23%

9%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Coinsurance

Copayment









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

81%

94% 93% 99%

19%

6% 7% 1%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Coinsurance

Copayment








Average Copayment for Preferred Drugs

$63

$47

$37

$28

$-

$10

$20

$30

$40

$50

$60

$70









Distribution of Copayment Amounts for Preferred Drugs

7%

25%

2% 5%

27%

57%

6%

24%

48%

13%

47%

58%

13%

4%

6%

9% 4%

39%

3% 2%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Over $60

>$50 - $60

>$40 - $50

>$30 - $40

>$20 - $30

20% or less








Average Coinsurance Rates for Preferred Drugs

32%

30%

27% 27%

24%

25%

26%

27%

28%

29%

30%

31%

32%

33%









Distribution of Coinsurance Rates for Preferred Drugs

2% 10%

17% 18%

24%

19% 12%

36% 39%

52%

64%

11%

11%

8% 27% 22%

11% 18%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


40% or more

>30% - >40%

>20% - 30%

>10% - 20%

10% or less








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

36%

20%

8%

20%

40%

52%

88%

44% 40% 40%

11%

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

56%

75% 78%

69%

44%

25% 22%

31%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Coinsurance

Copayment








Average Copayment for Non-Preferred Drugs

$106

$85

$74

$55

$0

$20

$40

$60

$80

$100

$120









Distribution of Copayment Amounts for Non-Preferred Drugs

1% 4% 8%

60%

34%

47%

66%

35%

30%

39%

22%

4%

27%

9% 2% 8%

1% 2%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Over $150

>$100 - $150

>$75 - $100

>$50 - $75

$50 or less








Average Coinsurance Rates for Non-Preferred Drugs

37% 37%

34%

33%

31%

32%

33%

34%

35%

36%

37%

38%









Distribution of Coinsurance Rates for Non-Preferred Drugs

2% 6%

13%

3%

17%

22%

19%

10%

29% 15% 10%

16%

51% 56% 58%

71%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


>30% - <50%

>20% - 30%

>10% - 20%

10% or less








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

36%

22%

10%

1%

3%

9%

8%

1%

61% 68%

82%

98%

1% 1%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Copayment and Coinsurance

Coinsurance

Copayment









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

12%

33% 34% 33%

88%

67% 65% 67%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Coinsurance

Copayment








Average Copayment for Specialty Drugs

$174 $179

$160

$139

$0

$20

$40

$60

$80

$100

$120

$140

$160

$180

$200









Distribution of Copayment Amounts for Specialty Drugs

16% 8%

15%

39%

25% 47%

58%

23%

39%

23%

13%

28%

12% 14%

5% 2%

8% 8% 8% 8%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Over $250

>$200 - $250

>$150 - $200

>$100 - $150

$100 or less








Average Coinsurance Rates for Specialty Drugs

36% 36%

30%

28%

0%

5%

10%

15%

20%

25%

30%

35%

40%









Distribution of Coinsurance Rates for Specialty Drugs

2% 4% 7% 8%

15% 17%

19% 11%

27% 23%

45% 52%

56% 56%

30% 29%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


>30% - <50%

>20% - 30%

>10% - 20%

10% or less







Emergency Room Cost Sharing


29%

8% 5% 1%

21%

46% 48%

37%

38% 28% 25%

34%

12% 18%

22% 28%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Copay & Coinsurance

Coinsurance

Copayment

No Charge afterDeductible

Share of Plans by Type of Emergency Room Cost Sharing








$264

$318

$252

$155

$0

$50

$100

$150

$200

$250

$300

$350


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








32%

28%

20%

22%

0%

5%

10%

15%

20%

25%

30%

35%


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







Out-of-Pocket Maximums


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

$6,359

$5,826

$4,529

$1,975

$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

$7,000









8%

91%

15%

47%

7%

72%

62%

40%

1%

28% 22%

5% 1%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


$6,600

>$4,500 to < $6,600

>$2,500 to $4,500

>$500 to $2,500

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







Health & Medicine

Cost Sharing in Marketplace Plans