Cost-Sharing and Access to Affordable Care

The state health exchanges exist to try to ensure everyone can access the care they need. Keeping health care affordable is a key component of keeping it accessible.

Everything from comparing plans and benefits to understanding deductibles and out-of-pocket costs can make the task of selecting a health plan from your state’s health insurance exchange challenging, particularly when variables and costs vary so drastically among plans, even within the same “metal level” (i.e., bronze, silver, gold, etc.).

But choosing a plan is just the beginning. Some patients and caregivers are learning their health care may cost more than they anticipated due to high cost-sharing, particularly when it comes to the cost of certain prescription drugs.

What is Cost Sharing?

Cost-sharing is the total amount a patient is responsible for paying for covered health care services or prescriptions. This includes any co-payments, co-insurance, or deductible payments. Even when you or your loved one has paid the deductible for the year, you can still face high out-of-pocket costs.

High cost-sharing may put certain medicines or treatments out of reach. And that can have negative consequences for patients’ health outcomes. That’s especially true for patients with significant chronic conditions or rare or acute diseases, for which treatment options may be limited.

What can be done

Some patients may qualify for subsidies (financial assistance) based on their income levels. These subsidies reduce the deductibles and other out-of-pocket costs those individuals or their family members are required to pay.

Some protections have also been put in place through the Centers for Medicare & Medicaid Services, but there is still more to do to ensure patients and caregivers who are not eligible for Medicare or Medicaid can afford the health care they need.

The Community for a Healthy Exchange believes that an important first step is making sure all patients and caregivers can more easily estimate their likely out-of-pocket costs when they are selecting a health plan on their state health exchange. Clearer explanations of benefits and cost-sharing levels will better position patients and their families to make informed choices.

Beyond greater clarity, we also believe additional discussion is needed about how benefit levels for different types of treatments are set, to ensure that those patients who most need quality health care don’t find themselves facing prohibitive costs.

There’s no question that cost-sharing is a complicated issue. We encourage you to start by taking the time to carefully review your or your loved one’s health plan (including deductible and other potential out-of-pocket costs) so that you have a better chance of knowing, upfront, what the impact will be to you and your family when using your coverage.

Have you run into challenges with out-of-pocket costs being higher than you expected? Tell us more here.

Have you been successful in selecting a health plan that keeps your out-of-pocket costs manageable? We’d also like to hear what you did to make the system work for you or a loved one. Tell us more here.

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