Patient Cost-Sharing Under The Affordable Care Act

posted by Federal Affairs

on November 19, 2015

Key Highlights

Protect individuals and familiesMaximum out-of-pocket limits included in the Affordable Care Act protect individuals and families from high medical spending, including those covered by Exchange plans in the individual market and employees and their dependents covered by small and large employers.

bronze, gold, silver, platinumConsumers enrolled through the Exchanges have a wide variety of plan choices – from platinum to bronze – that allow individuals and families to determine the combination of premium payments and out-of-pocket spending that best match their specific health care and financial needs. Lower income enrollees are further shielded from out-of-pocket spending as a result of enhanced cost-sharing reduction subsidies.

86% satisfied86% satisfied—A large majority of individuals covered through the exchange or expanded Medicaid are very or somewhat satisfied with their health insurance coverage. Consumers give their exchange plans high marks on choice of doctors, access to primary and specialty care, and cost-sharing features—such as co-payments for physician visits and prescription drugs.

93.3% cost coveredUnder the average bronze plan in 2015, at most an individual would be responsible for 6.7 percent of the total cost of the specialty drug Harvoni (used to treat chronic hepatitis C); the health plan would pay for 93.3 percent of the full cost.


This report summarizes the ACA’s provisions that are aimed at promoting comprehensive  coverage and limiting or reducing patient out-of-pocket costs. The report also details requirements in the law that mandate comprehensive coverage of prescription drugs – which is broadly similar to the scope of prescription drug coverage offered under similar employer sponsored plans and Medicare Part D.

The Affordable Care Act (ACA) requires health plans to provide comprehensive benefits in the individual and small-group marketplaces (both inside and outside the new Exchanges). The  essential health benefits (EHB) package requirements detail both the benefits required to be covered and how cost sharing is structured in the new marketplaces. Under the ACA, the EHB  provisions require insurers to:

  • Provide coverage for 10 broad categories of services as specified under the statute;
  • Limit annual cost sharing to specific amounts; and
  • Meet minimum standards for actuarial value.

Other ACA provisions reduce patients’ out-of-pocket expenses, most notably premium subsidies and cost-sharing reductions for low- and moderate-income families purchasing coverage through the Exchanges.

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