As a Certified Insurance Agent for Covered California I am scrupulous when it comes to reading each question on the application for health insurance exactly as written, except when the Covered California application asks for the sex of the applicant. Instead, I ask for the person’s or dependent’s gender. Covered California should stop asking about a person’s sex and allow them to specify a gender.
California individual and family plan health insurance carriers have been combating fraudulent enrollment for open and special enrollment periods. Many of the health insurance companies have placed additional requirements on applicants to verify California residency. Unfortunately, enrollments through Covered California, which have virtually no verification of special enrollment eligibility, continue to be a source of high-cost claims from fraudulent enrollments.
For individuals and families who do not qualify for the Covered California tax credits, there are some alternative off-exchange health plans that may save you money. Health plans offered off-exchange, or directly from the health insurance company, can have different plan design benefits than the standard benefit design available through Covered California. Not only are the rates for these non-standard benefit plans usually less, the design of the plan may save you and your family additional money.
Covered California sets the metal tier plan design for Qualified Health Plans (QHPs) that are eligible to receive the Advance Premium Tax Credit subsidy when enrolled through Covered California. These are the standard benefit designs. Health insurance companies also offer the standard benefit design plans off-exchange at the same rates. But many health insurance companies have created non-standard benefit design plans that also fall within the metal tier levels of Bronze, Silver, and Gold.
Because the non-standard benefit plans meet the actuarial level of the metal tier (Bronze 60%, Silver 70%, Gold 80%) their rates are fairly close to the standard benefit design plans. However, the health insurance companies have tweaked some member cost-sharing elements of the plans. For instance, a non-standard plan may have a higher deductible amount and lower copayments or coinsurance than a standard benefit plan. In addition to the lower premium rates, some of the lower cost-sharing benefits may actually be beneficial to some consumers who utilize different elements of a health plan. Some consumers are willing to accept a higher deductible if they receive lower copayments for offices, labs, or prescription drugs.
Here are a few of the non-standard benefit designs offered off-exchange from some of the health insurance carriers in California.
Anthem Blue Cross Bronze Pathway EPO/PPO* 6900
The Bronze 6900 has a $6,900 medical deductible versus $6,300 for a standard plan. But whereas the standard Bronze has only three office visits at a $75 copay, the Bronze 6900 has a $55 primary care office visits not subject to the deductible. Another benefit is going straight into Tier 1 and Tier 2 prescription drug copayments without meeting a pharmacy deductible. The Bronze 6900 might be great for someone who is generally healthy, can accept a high deductible amount, but needs to see their doctor on a regular basis and takes a couple of medications. It has the potential to save them some money over a Silver plan.
*Home address will determine if a EPO or PPO is offered in the region.
Blue Shield of California Silver Seven 3750
The Silver Seven 3750 has a $3,750 deductible versus $2,500 for a standard Silver plan. The Seven indicates the plan has $7 primary care office copays, $7 acupuncture visit copay, $7 Tier 1 generic drug copay, and $7 lab copay. The Tier 2 and 3 drugs also have a lower copay than standard Silver plan subject to the pharmacy deductible of $250. This plan would appeal to consumers who have frequent doctor office visits and labs to manage a chronic health condition, but are relatively healthy.
Kaiser Silver 70 HDHP HMO 2700/15%
The Silver 70 HDHP 2700/15% is H.S.A. (Health Savings Account) compatible with a $2,700 deductible. Like all of the High Deductible Health Plans, excluding preventive health care, nothing is covered until you meet the deductible. Most HDHP are Bronze plans and have a $4,800 deductible. In addition, the standard Bronze HDHP plans have 40% coinsurance after the deductible is met while the Kaiser Silver 70 2700/15% has 15% coinsurance. A major benefit with for a Kaiser H.S.A. plan is getting an accurate quote for health care services. Kaiser has a list of costs for the most common health care services and they are generally very reasonable compared to other hospitals. This plan should be considered by people who like the Kaiser model of health care, want the tax benefits of an H.S.A., but don’t want the higher $4,800 deductible of a standard Bronze HDHP.
Oscar Simple Bronze
The Oscar Simple Bronze plan is about as close to a major medical catastrophic plan as a person can get who does not qualify for the Minimum Coverage plans. The individual deductible is $7,150 and the only items that are covered are generic drugs at a $5 copayment. Oscar is an EPO so the member does have a selection of doctors and hospitals they can visit without a referral. The Simple Bronze is only offered in parts of Los Angeles County and all of Orange and San Francisco counties. For a 30 year old in those regions the Simple Bronze will still be slightly more expensive than the standard Bronze plans offered by Chinese Community Health Plan, Kaiser, L.A. Care, and Molina. This off-exchange plan would work for someone who is super healthy, never visits a doctor except for an annual physical (which is included at no charge), and can afford the $7,150 deductible in case of a major accident or illness.
Sutter Health Plus
Sutter Health Plus offers health plans in the greater Sacramento region and Bay Area. None of their plans are available through Covered California. However, the rates for the Sutter Health Plus HMO standard benefit design plans are very competitive. Virtually the only way you can get access to Sutter hospitals and doctors are with the Blue Shield plans. A Sutter Health Plus Silver 70 plan for a 40 year old in Sacramento County is $417.37, while Blue Shield PPO is $478.95. Sutter’s rates tend to be slightly higher than Blue Shield in San Francisco, but comparable in other areas around the Bay Area. If you are a fan of Sutter and their doctors, and don’t like the uncertainty that Blue Shield might drop Sutter facilities and doctors from their health plans, a Sutter Health Plan should be given serious consideration.
Western Health Advantage Silver 3600 H.S.A
The $3,600 deductible of the Western Health Advantage Silver 3600 HDHP is also the maximum out-of-pocket for the plan. Once the member has spent $3,600, all benefits of the health plan are covered 100% by WHA. Excluding preventive office visits which are $0 cost, the member is responsible for all the health care costs up to $3,600. That includes prescription medications. This plan would work for individuals and families who infrequently use health care services, but want the assurance that if something big happens; there will be a low maximum out-of-pocket amount.
For the first time in my life I can commiserate with people who are losing their livelihood because of a government action. Just as some workers have been displaced because the government outlawed a product, changed an environmental regulation, or enacted a trade deal that smothered their industry, I too am on the receiving end of government legislation that will decimate my income. If Obamacare is repealed and the subsidies that make health insurance affordable for millions of Americans ceases, I will lose 90% of my clients.
With the loss of the Anthem Blue Cross PPO plans in most of California and the double-digit rate increases on many plans, consumers are starting to look at the HMO plans available to them. There was a time when HMO plans were always more expensive than PPO plans. In the new health insurance landscape of Obamacare, HMO plans are becoming less expensive. But is a HMO plan right for you and your family?
The new Covered California Shop and Compare Tool, launched in late September 2016, is broken. The comparison to tool to allow consumers to estimate their monthly subsidy and compare health plans has been giving erroneous results. The worst part is that Covered California has known about the issue and has failed to alert consumers or agents that the tool is giving bad results.
One of the first filters in selecting an EPO or PPO individual and family plan, either through Covered California or off-exchange, is determining if your current doctor is in-network. For all the enhancements to online doctor directory search tools, they still suck. They are not consumer friendly. Consumers are given either too many conditions to select or the provider search tool offers too little information.
I would not have believed it had I not witnessed it with my own eyes. When I renewed the Covered California health plan for a client her monthly premium amount she will be responsible for will actually be lower in 2017. Even though the carrier had an overall rate increase and she was another year older, the Advance Premium Tax Credit monthly subsidy calculated by Covered California will be larger in 2017. The net result is she will be paying less than $5 per month for the same Silver health plan in 2017.
The Department of Managed Health Care (DMHC), who regulates most of the individual and family plans offered through Covered California, has developed a website to allow consumers to compare health insurance companies. The Health Plan Dashboard website does not assign any performance review ratings. But it does give consumers a high level view of some of the data collect on the health plans such as enrollment, complaints, and enforcement actions for medical, dental, and vision plans.
Even with the Obamacare subsidies, many individuals and families still opt for the least expensive Bronze high deductible health plans. The high deductible health plans require the consumer to spend $4,500 to $6,500 in a medical deductible before any real cost sharing with the health insurance company starts. As more consumers opt for these least expensive Bronze plans more insurance companies are creating insurance products to help cover the high deductible of these plans. But are these indemnity plans worth the money and will they actually pay when you need the money?