Lowest Premium Marketplace Health Plans Not Always Most Cost Effective for HIV Patients

A recent study by the Henry J. Kaiser Family Foundation evaluated the estimated costs of HIV positive patients when enrolled in marketplace health plans and which plans could offer the greatest value.

A key expansion of the Affordable Care Act (ACA) addressed the availability of private insurance coverage through health insurance marketplaces in every state.

There are several factors that go into choosing the optimal health plan. For patients with HIV, however, cost is a major concern area due to the expense of antiretroviral prescription medications.

Looking at premiums alone shows an inaccurate picture of how much the plan will cost, since enrollees can run into unexpected cost increases if premiums are used to guide plan selection in isolation, the study found. Other factors that need to be taken into account include deductibles and out-of-pocket (OOP) maximums.

The study looked at 300 different enrollment scenarios along with 5 plans in 5 states for 2 enrollee types with varying incomes. These enrollee type either had well-managed HIV and no other chronic health needs or they are HIV patients with significant health care needs and simultaneous chronic disease.

Researchers looked at costs with expected health expenses and total OOP liability.

The results of the study showed that plans with the lowest premiums were not necessarily the most cost effective.

Based off the scenarios used in the study, when evaluating the lowest income levels, the greatest access to cost-sharing reduction subsidies translated to the lowest costs being found in silver plans.

Those who had the lowest income level paid a larger chunk of their income towards health care costs compared with individuals in the highest income level. By enrolling in a cost-effective silver level plan, it could minimize the financial impact.

Lower income individuals on silver plans had the least liability, while platinum plans carry the least liability for those with higher incomes. This showed that enrolling in a high actuarial value plan when limiting financial risk would be best.

When aligned with the least OOP liability plan about half the time, the plan would give the enrollee the lowest health care costs. This allows enrollees to minimize expected costs and OOP liability.

However, decisions become complicated when these are not aligned, causing enrollees or third party payers to decide between paying more up front in known costs to reduce overall liability or to pay less and have higher liability if unexpected costs arise.

There was an average difference of $4054 between the annual projected cost when enrolled in the lowest health care cost plan compared with the highest. For liability, the difference was $3014 of expected annual cost in the plan with lowest liability compared to the highest.

Those with higher health needs on average can expect to pay an additional $400 in order to meet health costs compared with individuals with lower health needs. This had a substantial range when examined individually.

Compared with low health care need enrollees, high enrollees had additional spending from 0 to $1693. About 12% of the time, or in 37 scenarios, high health care enrollees had more than $800 in additional costs compared to low health care enrollees.