Reports & Analysis

Private insurance plans typically require some form of cost sharing (also called out-of-pocket costs) when enrollees receive a health care service covered by their plan.  These expenses, which are in addition to the amount an enrollee spends on his or her monthly premium, come in a variety of forms, including copayments, coinsurance, and deductibles. Insurers use cost sharing to keep down monthly premiums, but cost sharing can also lead to unexpected costs for some enrollees and can be difficult to decipher when shopping for plans or reviewing medical bills. This brief shows the cost sharing in plans sold to individuals through Healthcare.gov, with a focus on the variation in the ways plans may set cost sharing for services, such as physician visits, prescription drugs, and hospital stays.

In order to ensure that Consumer Services Divisions within state insurance regulatory agencies are equipped with the necessary resources to assist consumers experiencing insurance problems, the State Health Reform Assistance Network has developed a toolkit intended as a guide for consumer service representatives (CSRs). The resources in this updated toolkit include a reference manual with multiple entries across a number of categories, a glossary of acronyms, terms, and definitions, a benefits crosswalk template, and a reference table illustrating the applicability of ACA provisions to grandfathered and self-funded plans. 

The primary goal of the ACA is to increase access to health care by expanding health insurance coverage, but another major thrust of the law is support for innovation in health care delivery and payment aimed at improving patient care and population health and reducing health care costs. The ACA-established Center for Medicare and Medicaid Innovation (Innovation Center) within the Centers for Medicare and Medicaid Services (CMS) is testing an array of alternative payment and service delivery models through numerous demonstration and pilot programs designed to lower costs for Medicare, Medicaid, and the Children’s Health Insurance Program while maintaining or improving the quality of care for beneficiaries. This fact sheet provides an overview of one of these programs – the State Innovation Models (SIM) initiative.

With the support of The Commonwealth Fund, the National Association of Medicaid Directors (NAMD) brought together staff from states over a period of one year to focus on data analytics, practice transformation, and multi-payer alignment. While states were organized into different workgroups to address these issues, reform proved to be a wide-ranging topic. As these workgroups discussed their respective state’s work to drive innovation at the point-of-care for their beneficiaries, cross-cutting and coherent themes emerged. This brief reflects the discussions across the workgroups and all-state calls, and draws from state submissions to NAMD’s State Medicaid Operations Survey: Third Annual Survey of Medicaid Directors.

The second open enrollment period, during which eligible individuals may enroll in a Qualified Health Plan for 2015 in a marketplace, runs from November 15, 2014 to February 15, 2015. Some studies show that many do not understand the very terms and concepts necessary to make informed choices. For many people, it is the first time that they will have coverage. In addition, insurance is becoming more “consumer driven,” and often includes higher deductibles, which shifts financial risk to the patient. That increases the stakes and requires an even more sophisticated understanding of health insurance. This toolkit addresses the extent and significance of both health literacy and health insurance literacy for Americans buying and using health insurance.

New results from the Commonwealth Fund Biennial Health Insurance Survey, 2014, indicate that the ACA’s subsidized insurance options and consumer protections reduced the number of uninsured working-age adults from an estimated 37 million people, or 20 percent of the population, in 2010 to 29 million, or 16 percent, by the second half of 2014. Conducted from July to December 2014, for the first time since it began in 2001, the survey also finds declines in the number of people who report cost-related access problems and medical-related financial difficulties.

In the twenty-three states that have decided against expanding Medicaid under the Affordable Care Act, uninsured adults who would have been eligible for Medicaid and have incomes at or above the federal poverty guidelines are generally eligible for Marketplace premium tax credits and plans with generous benefits. This study compared estimated out-of-pocket spending for care and premiums, as well as the financial burdens they impose, for the families of these adults under two simulation scenarios: obtaining coverage through a silver plan with subsidized cost sharing and enrolling in expanded Medicaid. Compared with Marketplace coverage, Medicaid would more than halve average annual out-of-pocket spending ($938 versus $1,948), while dramatically reducing the percentage of adults in families with out-of-pocket expenses exceeding 10 percent or 20 percent of income.

The ACA has contributed to a significant transformation of Medicaid, broadening it as the base of coverage for the low-income population and accelerating state efforts to move from antiquated, paper-driven enrollment processes to a new modernized enrollment experience for individuals. January 1, 2015 marked the first anniversary of key ACA Medicaid provisions, including the Medicaid expansion to low-income adults and new rules for streamlined enrollment and renewal processes that coordinate across insurance affordability programs. This 13th annual 50-state survey of Medicaid and CHIP eligibility, enrollment, renewal, and cost-sharing policies as of January 2015 provides a snapshot of state Medicaid and CHIP policies in place one year into the post-ACA era.

During this second year of open enrollment in marketplaces, states are renewing current enrollees for the first time, in addition to enrolling new customers. Renewing coverage for existing enrollees is essential to avoid coverage gaps, but state approaches to renewals and re-enrollment in marketplace coverage vary. This chart looks at how states are handling Advanced Premium Tax Credits (APTC) and plan renewals for consumers already enrolled in a plan through the marketplace, as well as some of the resources states have produced to educate consumers.

The Supreme Court will hear the King v. Burwell case, in which the plaintiff argues that the ACA prohibits payment of premium tax credits and cost-sharing reductions to people in states without state-managed Marketplaces. This report estimates that a victory for the plaintiff would increase the number of uninsured by 8.2 million people and eliminate $28.8 billion in tax credits and cost-sharing reductions in 2016 ($340 billion over 10 years) for 9.3 million people. With lower cost individuals leaving the market, average nongroup premiums in 34 states would increase by 35 percent, affecting those purchasing inside and outside those Marketplaces.