Or he may pay over $5K before he can use it...
What are a bronze plan's out-of-pocket costs?
Bronze Plans are designed so that insurance companies will typically pay 60% of covered healthcare expenses with the remaining 40% to be paid by consumers. However, as illustrated below, this does not mean that the
insurer pays 60 cents of every dollar of healthcare
expense for an enrollee. The consumer’s expenses are in the form of out-of-pocket fees over and above the cost of the plan’s monthly premium. Out-of-pocket expenses in 2016 are capped at $6,850 for individual plans and $13,700 for family plans, though plans can apply lower limits if they so choose.
The 60/40 payments by
insurer versus enrollee are based on projected use of healthcare services by plan members. The actual out-of-pocket expenses of any single
beneficiary may work out to be more or less than this ratio. Those people whose out-of-pocket limits reach the annual maximum could see their share of covered healthcare costs discontinue until a new calendar year begins and the annual limit is reset.
Out-of-pocket expenses include fees like deductibles, copayments, or coinsurance. Different plans will approach the 60/40 split in various ways (see the table below) so it is important to research the financial details of a specific plan before deciding which one to purchase. For example, a person who has frequent medical expenses may want a Bronze Plan with a lower deductible (depending on premium) while a healthy person may want the opposite.
Below are the average out-of-pocket cost-sharing expenses for
medical services and
prescription drugs found across bronze plans offered on Healthcare.gov.
Cost-Sharing Category Average for a Bronze Plan
Deductible for an individual enrollee $5,731
Deductible for a family $11,601
Doctor Visit 32% of doctor visit
expense charged as coinsurance fee. Coinsurance was the most common form of cost-sharing for doctor visits among 2016 Bronze Plans
Generic drugs 32% of generic drug expense charged to patient as coinsurance fee (2014 data)
Preferred brand drugs 35% of preferred brand drug expense charged to patient as coinsurance fee (2014 data)
Non-preferred brand drugs 36% of non-preferred brand drug expense charged to patient as coinsurance fee (2014 data)
Specialty drugs 34% of specialty drug expense charged to patient as coinsurance fee (2014 data)
Specialist visit 31% of
specialist visit expense charged as coinsurance fee. Coinsurance was the most common form of cost-sharing for
specialist visits among 2016 Bronze Plans
Annual cap on
out-of-pocket costs for an individual $6,639
Annual cap on out-of-pocket costs for a family $13,292
