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Life Health > Health Insurance

Cap squeezes exchange plans

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It looks like an effort to hold down out-of-pocket costs for small-group exchange enrollees could backfire.

Critics of the Patient Protection and Affordable Care Act $2,000 cap on small-group exchange plan deductibles say enforcing the provision as written could wipe out the plans altogether.

Turmoil in the Small Business Health Options Program exchange plan market could have a direct effect on members of Congress and their staffers. PPACA requires them to get coverage through the public exchange.

The U.S. Office of Personnel Management requires the affected officials and government workers who live in the District of Columbia to get their coverage from the D.C. SHOP exchange.

PPACA imposes no caps on deductibles for private “qualified health plans” in the individual exchange market, but it imposes a $2,000 annual deductible for individual coverage and a $4,000 deductible for family coverage in the SHOP market.

The U.S. Department of Health and Human Services waived the deductible for 2014, to help plan issuers hold down co-payments, coinsurance rates and premiums.

In the individual market, issuers have coped with out-of-pocket cost maximum limit and affordability pressures by setting deductibles ranging from an average of $347 per enrollee in platinum plans to $2,907 for silver plans and $5,081 for bronze plans, according to HealthPocket.

In the SHOP market, the average deductibles are $323 for platinum plans, $1,278 for gold plans, $2,384 for silver plans and $4,216 for bronze plans, HealthPocket says.

About 96 percent of the SHOP individual bronze plans and 28 percent of the SHOP individual silver plans have deductibles over the caps, HealthPocket says.

Reps. Tom Reed, R-N.Y., and Mike Thompson, D-Calif., have introduced a bill that would lift the SHOP deductible cap, and eliminate the possibility HHS might try to enforce it in 2015.

The bill has the support of the National Association of Health Underwriters, but has been languishing in the House Energy & Commerce Committee since August and has just five cosponsors.

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