More than 2 million public exchange enrollees eligible for cost-sharing reductions are not receiving the subsides because they selected a non-qualifying plan, a recent analysis from consultancy Avalere has found. The oversight could have been avoided with better decision-making tools and the help of trusted advisers, benefit experts agree.

These cost-sharing reductions are in addition to the more publicized tax credits.  The cost-sharing reduction only applies to plans in the silver metal level status and are for enrollees with incomes between 100% and 250% of the federal poverty level ($11,770-$29,425.)

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Washington-based Avalere found that of the 8.1 million individuals who enrolled in exchanges in 2015 who earn incomes that are eligible for the cost-sharing reductions, just 5.9 million are actually receiving them. That leaves 2.2 million consumers potentially paying more out of pocket than the Affordable Care Act intended because they selected a plan that does not qualify, the consultancy notes.

Most likely, consumers are picking plans on exchanges based on premiums, rather than out-of-pocket costs, says Avalere CEO Dan Mendelson. “As a result, some patients may be paying more than they need to for care,” he says. “While cost-sharing reductions can help reduce what patients pay when they visit a doctor or hospital, some consumers may be unaware of the potential benefits.”

B. Ronnell Nolan, CEO of agent lobbying group Health Agents for America, says that the fact this money is not being accessed is a “thorn in [her] side” and a result of Americans not getting access to experts agents and brokers.

“Instead, they are meeting with navigators and [certified application counselors] who are not trained properly and being sold, not enrolled [in] the cheapest plan,” she says. “Upon arrival at the hospital, the hospital is going to ask these people who are on a fixed budget for a huge deductible before the procedure and they are going to be blindsided.”

“It really hurts my heart, a law passed to help those that do not have insurance is simply not doing that,” she adds.

An ongoing issue

The Congressional Budget Office estimates consumers will continue to forgo these reductions in the future. CBO estimates that 3 million individuals who are eligible for cost-sharing reductions will forgo subsidies by signing up for a bronze plan in the years after 2015.

“Over time, exchanges really could help consumers with their decision making by giving them tools that calculate not just expected monthly premiums but also expected out of pocket costs,” says Elizabeth Carpenter, vice president at Avalere, agreeing that education can help individuals make smarter decisions.

“Many consumers might be better off paying a little bit more per month in exchange for lower out-of-pocket costs when they visit a doctor or pharmacy,” she says.

A recent study by researchers from the Perelman School of Medicine at the University of Pennsylvania analyzed Healthcare.gov and 12 state-run exchanges and found that while most sites allowed consumers to sort or filter plans by premium and deductible amounts, only three states had out-of-pocket cost estimators that “did the math” for consumers by adding together premium and expected costs, such as deductibles and copays based on consumers’ predicted use.

While Covered California listed plans in order of this estimated out-of-pocket cost from cheapest to most expensive, most sites the researchers analyzed used the premium amount as their default order, failing to account for most out-of-pocket expenses, such as a high deductible. All but six sites reviewed also failed to provide a tool to allow consumers to search plans for a provider network.

A lot of money is being left on the table, says Katherine Hempstead, a director at the Robert Wood Johnson Family Foundation.

“Better decision support definitely seems like part of the solution, but you also might wish for some design tweaks, such as permitting cost-saving reductions with bronze plans, or even more simply, just enriching the subsidies for consumers in this income range,” she says. “I think an important and yet unanswered question is to what extent under-enrollment in cost-sharing reductions affects retention. If that turns out to be non-trivial, we need to re-double our efforts to connect people with these benefits.”

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