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Study: 1 in 3 plans exceed ACA out-of-pocket limits


By: 
Anthony Brino

When deductibles are taken into account, about one-third of individual and family health plans currently exceed the Affordable Care Act's baseline limit on out-of-pocket expenses, researchers at the consumer website HealthPocket.com estimate.

Analyzing federally-collected data on 9,752 individual and family insurance plans, Kev Coleman, HealthPocket.com’s head of research and data, found a national average of $6,019 in out-of-pocket expenses (including deductibles), a bit shy of the ACA’s bronze-level cap of $6,250 per year.

State averages, though, varied from $3,192 in New Jersey, to $10,013 in Vermont, with 15 states exceeding the bronze-level limit, which takes effect in 2014.

The analysis also found that 38 percent of plans studied did not include the deductible within their out-of-pocket limit, “concealing the full amount a beneficiary could pay annually if the Summary of Benefits wasn’t read carefully,” said Coleman, a former eHealth product development VP who previously helped launch the lead generation software provider Experion Systems.

The study found Vermont, Florida, Alabama, Arizona, Oregon and Washington had average out-of-pocket expenses more than $1,000 over the ACA’s limit, while Georgia, Mississippi, Arkansas, Michigan, Minnesota, Texas, Idaho and Montana had average -out-of-pocket costs of less than $1,000 over the $6,250 bronze threshold.

Fourteen states, including Maine, Massachusetts, Indiana and New York, had average annual out-of-pocket costs of less than $5,000, with New Jersey, Hawaii and North Dakota having average out-of-pocket costs under $4,000.

Coleman said the ACA’s cap on out-of-pocket costs, with insurers required to include deductibles in the calculation, “will have a highly regional impact, with consumers in states such as Vermont, Washington, Oregon, Alabama, and Florida seeing some of the biggest benefits.”

The ACA reduces the out-of-pocket limit for people with lower incomes, providing a 33 percent reduction for people with adjusted gross income between 300 and 400 percent the federal poverty level (FPL) and a 66 percent reduction for people below 200 percent FPL.

In terms of the consumer benefits of the cap by demographics, Coleman thinks the out-of-pocket limits are likely to have “a disproportionate value to moderate and higher income Americans facing chronic diseases or persistent poor health, since this group is most likely to reach the annual limits.”

Founded by former eHealth executives last November, HealthPocket.com is trying to fill what it sees a transparency gap for health insurance consumers, including seniors shopping for Medicare Advantage. In another recent study of a practice being phased out under the ACA, HealthPocket.com found that about 20 percent of health plan applications were initially rejected.   

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