SECTION7. EMPLOYEECOSTSHARING Section7 EmployeeCostSharing In addition to any required premiumcontributions,mostcoveredworkersfacecostsharingforthemedicalservicestheyuse. Costsharingformedicalservicescantakeavarietyofforms,includingdeductibles(anamountthatmustbepaidbeforemost services are covered by the plan), copayments(fixeddollaramounts),andcoinsurance(apercentageofthechargeforservices). Thetypeandlevelofcostsharingoftenvarybythetypeofplaninwhichtheworkerisenrolled. Costsharingmayalsovaryby thetypeofservice,suchasofficevisits,hospitalizations,orprescriptiondrugs. Thecost-sharingamountsreportedhereareforcoveredworkersusingservicesprovidedin-networkbyparticipatingproviders. Planenrolleesreceivingservicesfromprovidersthatdonotparticipateinplannetworksoftenfacehighercostsharingand mayberesponsibleforchargesthatexceedplanallowableamounts. Theframeworkofthissurveydoesnotallowustocapture all of the complex cost-sharing requirementsinmodernplans,particularlyforancillaryservices(suchasdurablemedical equipmentorphysicaltherapy)orcost-sharingarrangementsthatvaryacrossdifferentsettings(suchastierednetworks). Therefore, wedonotcollectinformationonallplanprovisionsandlimitsthataffectenrolleeout-of-pocketliability. GENERALANNUALDEDUCTIBLESFORWORKERSINPLANSWITHDEDUCTIBLES • Ageneralannualdeductibleisanamountthatmustbepaidbyenrolleesbeforemostservicesarecoveredbytheir healthplan. Non-grandfatheredhealthplansarerequiredtocoversomeservicessuchaspreventivecarewithoutcost sharing. Someplansrequireenrolleestomeetaservice-specificdeductible,suchasonprescriptiondrugsorhospital admissions,inlieuoforinadditiontoageneralannualdeductible. – Eighty-onepercentofcoveredworkersareenrolledinaplanwithageneralannualdeductibleforsinglecoverage, similar to 83% in 2016, but an increase from 72% in 2012 [Figure 7.2]. – Thepercentageofcoveredworkersenrolledinaplanwithageneralannualdeductibleforsinglecoverageis similar for small firms (3-199 workers) and large firms (200 or more workers) (77% and 83%) [Figure 7.2]. – Thelikelihoodofhavingadeductiblevariesbyplantype[Figure7.1]. CoveredworkersinHMOsarelesslikely tohaveageneralannualdeductibleforsinglecoveragethanworkersinotherplantypes. Sixty-twopercentof workersinHMOsdonothaveageneralannualdeductibleforsinglecoverage,comparedto35%ofworkersinPOS plansand14%ofworkersinPPOs. • Forcoveredworkersinaplanwithageneralannualdeductible,theaverageannualdeductibleforsinglecoverageis $1,505,similartotheaveragedeductible($1,478)lastyear[Figures7.3and7.10]. – Forcoveredworkersinplanswithageneralannualdeductible,theaveragedeductiblesforsinglecoverageare $1,175inHMOs,$1,046inPPOs,$1,301inPOSplans,and$2,304inHDHP/SOs[Figure7.6]. – Theaveragedeductiblesforsinglecoveragearehigheracrossplantypesforcoveredworkersinsmallfirmsthan for coveredworkersinlargefirms. ForcoveredworkersinPPOswithageneralannualdeductible,forexample,the averagedeductibleamountforsinglecoverageinsmallfirmsismuchhigherthantheaveragedeductibleamount in large firms ($1,594 vs. $856) [Figure 7.6]. Overall, for covered workers in plans with a general annual deductible, theaveragedeductibleamountforsinglecoverageinsmallfirmsishigherthantheaveragedeductibleamountin large firms($2,120vs. $1,276)[Figure7.3]. – Amongcoveredworkersinplanswithageneralannualdeductible,theaveragedeductibleforworkersinfirms witharelativelylargeshareoflower-wageworkers(whereatleast35%ofworkersearn$24,000ayearorless) The Kaiser Family Foundation and Health Research & Educational Trust / Page 98