Although states have authority to require health insurers to cover certain benefits or to adjust cost-sharing to lower financial barriers to care, a study by the Georgetown Health Policy Institute found that only six states and the District of Columbia (DC) currently establish cost-sharing standards for specific services in individual and small-group health plans, doing so through standardized plan designs that insurers are required to offer. The study concludes that despite the call for greater state autonomy in establishing health insurance coverage standards, states may wish to consider requiring coverage of services pre-deductible or establishing cost-sharing limits for specific services in order to improve consumer access to necessary care.
The study, entitled "State Efforts to Lower Cost-Sharing Barriers to Health Care for the Privately Insured," published by the Urban Institute’s Health Policy Center, discusses findings from the review of policies in the 50 states and DC that regulate cost-sharing for consumers and from interviews with officials and health care stakeholders about the development and implementation of these policies.
State analysis. The study of the state policies found that California, Connecticut, Massachusetts, New York, Oregon, and Vermont have policies aimed at lowering cost-sharing for specified health care services in the individual and small-group markets through state required standardized plans. The study also found that DC has pursued a similar policy through standardized plan designs, but only for the individual market. Additional study findings include, but are not limited to, the following:
- Decisions to standardize benefit designs in these six states were largely driven by Marketplace officials under the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148), even though insurers are required to offer these plans inside and outside the Marketplaces.
- New Jersey also has standard plans, but the plans predate the ACA and explicitly waive the deductible for immunizations and lead screening for children, preventive care, maternity care, and second surgical opinions.
- In all the states except New York, standardized benefit plans include the following pre-deductible services with low to moderate copayment amounts: doctor’s visits for non-preventive primary care, specialty care, mental health and substance use disorder treatment, and urgent care, as well as generic prescription drugs in the silver and bronze plans.
- Routine pediatric care such as eye exams and dental exams are available pre-deductible with little or no copayments in California, Connecticut, DC, and Vermont.
- New York’s standardized plan design differs from the other states’ because it only provides access to prescription drugs (generic and brand-name) pre-deductible and does not require coverage of any medical services pre-deductible.
- Massachusetts’s ConnectorCare program, available to people with incomes below 300 percent of the federal poverty level, eliminated cost-sharing for opioid addiction treatments in its standardized plans.
- California, Connecticut, DC, and Vermont have mandated separate prescription drug deductibles, but Massachusetts limits prescription drug deductibles if they are present.
- In Massachusetts, all three tiers of prescription drugs are available pre-deductible with copayments of $20, $60, and $90.
- Connecticut makes the first three tiers of prescription drugs available pre-deductible with copayments of $5, $35, and $60, and places out-of-pocket limits on the fourth tier.
Marketplace and stakeholder input. The study found that Marketplace officials believe that providing some pre-deductible coverage is an important enrollment retention tactic. While insurer respondents shared similar views, the study found that not all supported Marketplace control over plan design. A review of Marketplace and stakeholder input also showed that:
- States developed standardized plan designs for their Marketplaces with significant input from insurers and consumer advocates.
- Because the cost-sharing associated with specific covered services under the ACA must apply within the context of the federally set actuarial value levels, many respondents described the process of deciding what to provide pre-deductible as a series of trade-offs.
- Although one insurer asserted that their state’s requirement of pre-deductible coverage had prompted higher use of health care services, most insurer respondents and state officials did not have data on enrollees’ use of services covered pre-deductible.
Although data on consumer use of services or health outcomes of plans with pre-deductible coverage were not yet available, the study found that most stakeholders believe that plans with pre-deductible services offer consumers a better value than plans that do not.
Companies: Georgetown Health Policy Institute; Urban Institute
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