Altered State: Health Care Reform and the Medicare Market
2012 health plans benchmark summary
1.
2. WELCOME
The 2012 Health Plans Benchmarking Report consists of data gathered from
nearly 50,000 employers and more than 73,000 health plans 1 during the 2012
calendar year. It offers benchmarking information for six key design measures:
Individual Out-of-Pocket Maximum
Individual Deductible
Emergency Room Copay
Coinsurance
Office Visit Copay
Prescription Drug Deductible
To help you compare your offerings against similar organizations and plans, we’ve
broken down the data by region, group size, industry and plan type for each item.
If you’re looking for expanded data on
any of these benchmarks, the drill-down
tool can be accessed here.
1
* Though this is a large sample size, care should be taken in applying and interpreting this data. It has not been
validated for statistical significance or margin of error. It is informational in nature and should be used in conjunction
with the advice of a licensed insurance broker.
2012 HEALTH PLANS BENCHMARK SUMMARY | 2
3. DEMOGRAPHICS
REGION
The 2012 report includes benchmarking information for Canada for the first time.
As in years past, it also includes information for the United States broken down
into five distinct regions:
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4. DEMOGRAPHICS
PLAN TYPE
The following plan types were represented in the 2012 data.
PPO 42.74%
POS 14.18%
Indemnity 0.19%
HSA 20.75%
HRA 2.11%
HMO 20.03%
Note: 43% of respondents entered their plan type as ‘Unknown,’ that data is not included.
INDUSTRY
The same industries were represented in the 2012 data as last year, with the
following breakdowns.
Transportation / Comm / Utilities 3.38%
State / Local Government 2.65%
Service 22.39%
Retail 7.06%
Other 15.81%
Mining / Construction / Wholesale 11.29%
Manufacturing 10.88%
Healthcare 13.58%
Finance / Insurance / Real Estate 8.98%
Education 2.10%
Agriculture / Forestry / Fishing 1.88%
GROUP SIZE
Group size broke down in the following way, with <25 being the most popular
group size represented in the data.
54.24%
14.15% 11.99% 14.93%
2.28% 1.27% 0.38% 0.76%
< 25 26 - 50 51 - 99 100 - 500 - 1,000 - 2,500 - 5,000 +
499 999 2,4999 4,999
2012 HEALTH PLANS BENCHMARK SUMMARY | 4
5. INDIVIDUAL OUT-OF-POCKET MAXIMUM
The most common range for an individual out-of-pocket maximum was $2,500-
$3,499, with 32% of plans favoring this option. This has not changed from the
2011 analysis.
When looking at regional selections, the Northeast region differed slightly
from the national trend with $5,000-$7,499 being the most popular
choice, though $2,500-$3,499 was a very close second.
Looking at this design measure by industry revealed an interesting change
from 2011 to 2012 in the State and Local Government industry, with the
highest option, $7,500, gaining significant popularity going from just 2%
of plans in 2011 to 16% in 2012 and the third most common option.
As far as the effect of plan type on this measure, there are some notable
differences for HSA and POS style plans.
HSA showed a markedly flatter distribution for ranges between
$2,500 and $7,499 compared to the national average, with only
14% of HSA plans opting for an OOPM outside that range.
The overwhelmingly most prevalent range for the POS plan type
for 2012 was $2,500-$3,499, which was featured in nearly 40%
of all POS plans. The rest of the POS plan OOPMs were flatly
distributed among the remaining ranges, with no single range
featured in more than 15% of POS plans.
When comparing different size groups, smaller employers tended to offer
plans with higher out-of-pocket maximums.
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6. INDIVIDUAL DEDUCTIBLE
The $2,500+ range remained the most common range for individual deductible,
becoming even more popular. The popularity of the rest of the ranges continued to
level out, and of these ranges, only the $1,000-$1,499 became more common,
growing from 11% to 15% in 2012.
Though the $0-$249 range was only the sixth most commonly offered
plan nationally, it ranked as the third most popular plan in the Northeast
region and was offered in 12% of plans, 5% higher than the national
average.
The two largest outliers in the industry category were the Education and
the State/Local Government industries, the former of which had 14% of
plans featuring an individual deductible in the $0-$250 range, nearly
twice the national average. The State/Local Government industry featured
an even greater number of plans in that range—18%—which made it the
second most common range in that industry. At the other end of the
spectrum, Retail featured the highest concentration of plans in the
$2,500+ range, with 44% of all plans offering a deductible in this range.
The HRA plan type is heavily weighted to the upper end the of scale, with
47% of all plans offering an individual deductible in the $2,500+ range,
and only 6% of plans offering a deductible of less than $1,000. Because
HSAs are required to be offered with an HDHP, the numbers were even
more weighted toward the upper end of the scale, with 72% in the
$2,500+ range, and fewer than 1% offering an individual deductible of
less than $1,000.
For the most part, employers with fewer than 500 employees tended to
offer individual deductibles toward the higher end of the scale, but in line
with the national average. Employers with more than 500 employees tend
to offer a more diversified range of deductibles.
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7. EMERGENCY ROOM COPAY
Again in 2012, offered emergency room copays tended to skew towards the higher
end of the scale, with more than 73% of all plans featuring an emergency room
copay of more than $100. Offering a high ER copay has become a common cost
control strategy to encourage employees to only seek emergency room care in the
case of actual medical emergencies.
The biggest departure from the national average in terms of region is the
Northeast, which features a far more diverse range of ER copays offered.
In this region, the most popular copay, the $100-$124 range, only makes
up 26% of total plans, which is much smaller than the most popular
range nationally (46% chose the $150+ range).
For 2012, employers with fewer than 500 employees seemed to trend
closer to the national average in terms of ER copay. Employers with 500
employees or more generally featured a more diverse group of ranges,
though employers with 5,000+ employees also fell very close to the
national average.
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8. COINSURANCE
Between 2011 and 2012, there was less than 1% change for any given range of
coinsurance amount offered. The most common coinsurance amount remains
100%, followed closely by the range 80%-89%.
Interestingly, 3 of the 5 regions (North Central, South Central and West)
all feature 80%-89% as their most common coinsurance range, with the
national average, 100%, following in second. The Northeast skews the
national average by greatly favoring the 100% coinsurance rate, featuring
it in nearly 70% of all health plans.
The coinsurance percentages differ very little between industries, though
the Agriculture/Forestry/Fishing, Retail, and Transportation/Comm/Utilities
industries favor the 80%-89% coinsurance range over the 100%
coinsurance very slightly—the opposite of the national average.
The HMO, HRA and HSA plan types offer a 100% coinsurance with much
greater frequency than the national average, with over 60% of each of
these plan types favoring this range. Meanwhile, the indemnity plan type
is heavily weighted toward the 80%-89% range, at 66%. PPO plans also
favor the 80%-89% range, but only 43% of those plans fall in to this
range, making it the most evenly distributed type of plan in regards to
coinsurance.
According to 2012 data, employers with fewer than 100 employees tend
to favor a coinsurance rate of 100%, while employers with 100
employees or more will likely favor a coinsurance rate in the range of
80%-89%.
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9. OFFICE VISIT COPAY
The average office visit copay in 2012 once again clusters in the range of $20-
$34 dollars, with 67% of all health plans charging a dollar amount in that range.
The only major change this year is that the percentage of plans charging between
$0 and $9 nearly doubled from 2011, up to 9%.
The State/Local Government industry is the true outlier in terms of
industries, as 28% of plans within this industry offer an office visit copay
of $0-$9.
For smaller employers, the most commonly offered office visit copay falls
in the $30-$34 range, but employers with 100 employees or more tend
to offer plans with an office visit copay in the $20-$24 range.
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