Cost Sharing
The ACA contains a number of provisions designed to reduce cost-sharing and out-of-pocket costs associated with essential health benefits for low-income individuals in the exchange.
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- Sarah Goodell
Virginia
Contact - Dan Cunningham
New York
Contact - Rebecca GwiltVirginia
Contact - Colin Reusch
District of Columbia
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Virginia
I understand that QHPs do not have to offer a pediatric dental benefit to be certified as long as there is a standalone dental plan with pediatric dental EHB offered by the Exchange. I assume, therefore, that it is possible that a person selects separate medical and standalone dental QHPs that are issued by different insurers. How do those insurers coordinate to ensure that cost sharing requirements and limits are met (between the two plans)? Do those insurers need to coordinate?
District of Columbia
It depends. First of all, as long as the state doesn't choose to prohibit it, QHPs can offer the pediatric dental benefit as part of their product so that consumers do not necessarily have to purchase separate dental coverage for their children. Under this scenario, no coordination of cost-sharing is necessary as it is all one plan.
Medical and dental plans may also enter into a contractual arrangement to offer a sort of bundled product under which they would need to coordinate in order to share the same out-of-pocket maximum.
The Final EHB rule also allows stand-alone dental plans to have a separate out-of-pocket maximum so that no coordination is necessary. However, under this scenario, a family's overall out-of-pocket maximum is increased by the amount established for the stand-alone dental plan meaning that their potential out-of-pocket expenses are significantly higher. We are seeing plan designs submitted in some states that allow for additional maximums as high as $1,000 per child.
From the consumer's perspective, under the current rules, a pediatric dental benefit that is embedded within a QHP is likely the best option as it shields them from any additional out-of-pocket maximums, assures a family the full range of consumer protections, and a premium tax credit that covers the cost of their children's dental coverage.
New York
We're working to understand definitions, concepts and terminology. There were a couple we didn't understand. 1. Could you tell us the definition of 'Full Actuarial Value'? 2. There's a reference to 'actuarial equivalencies' and '60%, 70%, 80% and 90'. Could you expand further on this concept?
Thanks, Dan Cunningham
Virginia
The Synthesis Project, an initiative of the Robert Wood Johnson Foundation, recently published a synthesis of the literature on cost-sharing. The author, Kathy Swartz, examined the evidence of cost-sharing on health spending, utilization, outcomes and whether responses to cost-sharing differ by socioeconomic factors and health status. I've uploaded the research synthesis and the companion policy brief.