New for 2016 is a Blue Shield individual and family health plan that offers $7 primary care office visits. The new Blue Shield of California Silver Seven 3750 PPO also has $7 lab tests as well. The trade-off for the low $7 office visits and other health care services is $3,750 deductible and 30% coinsurance for services subject to the deductible. The new Silver Seven 3750 plan is only offered off-exchange directly from Blue Shield and is not eligible for the premium tax credits offered by Covered California.
$7 office copayment reduces expenses
With the launch of Covered California and the demise of many grandfathered health plans, Californians have had a limited variety for unique health plan designs in the market place. While the Blue Shield Silver Seven 3750 PPO isn’t right for everyone’s circumstances, it is a nice alternative for individuals whose health challenges require a relatively high frequency of routine office visits and lab test. The standard benefit design plans approved by Covered California work well for many families, but there is a segment of the population that would like a health plan more suited for their particular circumstances.
Silver Seven 3750 with low $7 costs
The silver designation the of the Blue Shield Silver Seven 3750 PPO indicates that it will cover 70% of the average health care costs of the members who enroll in the health plan. In order for the plan to meet the actuarial value of 70%, Blue Shield had to tinker with the other covered essential health benefits covered in the plan. If the insurer lowers the member’s expense in one category, they must necessarily increase the cost of another category. Because this Silver Seven 3750 is designed to meet a 70% actuarial value, the premium rates will be close to that of other silver plans.
Silver Seven 3750 PPO $7 copayment health care services include
- Primary care physician office visit
- Other practitioner office visit
- Allergy testing office visits
- Outpatient diagnostic laboratory and pathology performed in a hospital
- Tier 1 generic drugs (not subject to pharmacy deductible)
- Routine outpatient mental health and behavioral health services
- Postnatal physician office visit
$35 Tier 2 Drugs
Another deviation from the standard benefit design silver plans is that the Silver Seven 3750 has Tier 2 Brand name drugs at $35 per prescription after the pharmacy deductible. Most health plans have Tier 2 drugs at a $50 after the deductible. The pharmacy deductible is $250 and Tier 4 drugs are capped at $250 per drug per month after the deductible is met. Specialist office visits are $35 and are not subject to the medical deductible.
Higher deductible and coinsurance
The annual out-of-pocket maximum amount is $6,500 per individual and $13,000 per family with in-network participating providers. A member must meet a $3,750 deductible for high cost services before they enter cost sharing of 30% coinsurance. The deductible is higher than the standard benefit design silver plan of $2,250 for 2016. The coinsurance for the Silver Seven 3750 plan at 30% is also higher than the 20% for the standard silver plan.
Are your doctors in-network?
A key component of any health plan should be if it covers the family’s preferred doctors, hospitals, and other providers. If it doesn’t, it may be of little use even if the premium is low and the benefits are great. Always read the fine print of the documents and conduct a provider search to verify who is a participating provider. Also, check the drug formulary to make sure all your drugs are listed and will be covered by the health plan.
Comparable silver metal tier rates
The Blue Shield Silver Seven 3750 PPO is not offered through Covered California and is therefore not eligible for the premium tax credit assistance, but it should be. The plan meets the actuarial value of 70% just like the other standard benefit design plans. The rates for the various Blue Shield Silver plans are comparable and all cover all the essential health benefits.
|Los Angeles County||Region 16||Monthly Rates|
|Age||Silver 70||Silver Seven 3750||Silver 1850|
Californian’s should have more choices through Covered California to select a health plan that better addresses their specific health care challenges. One size does not fit all, especially when it comes to health insurance.
- Visit Blue Shield page to download health plan material
- For a Blue Shield Quote