Concerns with

Out-of-Pocket Costs

Rising Healthcare Costs for Patients

To help address the rising cost of healthcare and prescription drugs, many insurers are implementing plans that shift more of the cost to patients. For example, these cost-sharing approaches include high deductibles that patients must meet before their healthcare or medications are fully covered and coinsurance, in which patients must pay a percentage of total costs rather than a set copay. High deductibles and coinsurance are difficult to avoid when shopping for a health plan, as these cost-sharing techniques are a standard feature of plans available today.

Impact on Patients

Although cost-sharing approaches can be costly for any patient, plans with high deductibles and coinsurance are particularly burdensome for patients with chronic diseases who require specialized care and medication for months or years at a time.

These patients are likely to have to pay their full deductible every year, often within a relatively short timeframe. Even after they have met their deductible, they are required to pay a percentage of prescription drug costs, which are costly for the specialty tier medications used for many chronic diseases.

Coinsurance requirements also make it difficult to budget for their health expenses each year because they must pay a percentage of their overall healthcare costs rather than just a deductible and set copays.

Our Work

The SAIM Coalition works to limit the burden of out-of-pocket by advocating for laws and regulations that require insurers to offer copay only cost-sharing insurance products in which the copays are proportionate to formulary tiers. Click here to see where the Coalition is working and which states have already passed legislation.