There have been few changes to the standard benefit design between 2014 and 2015 health plans offered through Covered California. A comparison of the metal levels offered in 2014 to the standard benefit design announced by Covered California for 2015 individual and family plans reveals modest changes to copayment amounts for prescription drugs, maximum out-of-pocket amounts and the hidden addition of pediatric dental to all plans. Side by side comparison at end of the post.
Generic prescription copayment reduced
For the 2015 health plan year, generic prescription medications will have the applicable copayment reduced from $19 to $15 for the Bronze through Gold standard plans. This will undoubted help some people, but many generic medications, especially for antibiotics, are routinely priced under $10 for a 30 day supply at the larger pharmacies.
Smaller annual out-of-pocket maximum
A more significant, but not dramatic, change is the lower annual Maximum Out-of-Pocket (MOOP) amount which was reduced by $100 for an individual and $200 for a family plan. Once an individual or family meets their MOOP the health plan picks up the cost of all copayments and coinsurance for covered health care benefits provided through in-network providers for the remainder of the calendar year. This reduction to the MOOP only applies to Bronze through Gold plans. The individual MOOP for 2015 will be $6,250, down from $6,350 in 2014.
Actuarial values drive premium
The health plans are marketed by their actuarial value. For example, the Bronze plan is expected to cover 60% of an average plan member’s yearly health care expenses. The reduction of the MOOP indicates that the existing plans were predicted to cover less than the actuarial value of 60% – 90% for Bronze through Platinum in the coming year.
Enhanced Silver 73 deductible and office copay bumped up
The one plan that had notable deductible and copayment increases is the Enhanced Silver 73 plan. The deductible for this plan is increasing by $100 for and individual, $200 for a family. In addition, the brand name prescription drug copayment is increasing from $30 to $35.
Children’s dental included with all plans
Unlike 2014, all 2015 health plans will include not only pediatric vision but dental benefits as well. For 2014 health plans, the Covered California Board made the un-wise decision of making children’s dental plans separate and optional. (See: Where’s the Children’s Dental Plans?). For the first half of the open enrollment period, families were not even prompted to select a pediatric dental plan for an additional monthly premium. The children’s dental plan, available to all individuals 18 years and younger, is built into every health plan for 2015.
Will the dental plans be any good?
What wasn’t revealed in the Covered California announcement was the type of pediatric dental plan to be offered. There were several plans available last year from HMOs to PPOs and the choice of a High or Low benefit plan. Families might find themselves stuck with a low benefit HMO plan that doesn’t support their dentist in their 2015 health plans.
Will the provider networks improve?
However, for many individuals and families, the coinsurance and copayments were irrelevant since their chosen doctor or hospital wasn’t in-network for their selected health plan. The tight and tiered networks were one way that the PPO health plans contained their costs. It will be interesting to see what new measures the health plans take to limit their claims expenses or increase consumer costs in 2015. We know that one health plan has already eliminated their PPO offering and will only offer EPO and HMO plans for 2015. More specifics will be revealed when the carriers release their Summary of Benefits and Charges (SBC) and the Evidence of Coverage (EOC) for the new health plans.
No limited on the cost of health care services
HMOs or Health Maintenance Organizations generally offer a more stable provider list than their PPO counter parts. But some HMO’s like Kaiser can also set their prices for health care services. For example, an HMO member can’t visit the MRI imaging center down the road even if the cost is half the price that the HMO charges. High priced and infrequent health care services (In-Patient/Imaging) fall under a specific coinsurance percentage for each plan. If the charge for an HMO MRI is $2,000 and the coinsurance is 20%, then the member is responsible for $400. Unfortunately, the consumer might have been able to get the same MRI through a PPO for less if the retail price of the MRI was $1,000 at an out-patient imaging center. When the same 20% coinsurance is applied, them member would be responsible for only $200.
Health Savings Accounts trap
Consumers should be very careful of the H.S.A. health plans that have an aggregate deductible and MOOP. On a family H.S.A. plan, an individual that becomes ill or has an accident will have to meet the aggregate of the family deductible before the 40% coinsurance is applied. Similarly, the individual on a family plan will have to meet the family MOOP before all benefits are covered by the health plan. Consumers should carefully read their Evidence of Coverage to see how their health plan is handling the H.S.A. family deductible for both “in” and “out-of-network” providers. (See: HSA plans double the deductible)
2014 versus 2015 Standard Benefit Design Comparison
This applies to in-network providers only.
2014 |
2015 |
|
Bronze |
||
| Ind. Med. Deductible | $5,000 | $5,000 |
| Rx Deductible1 | N/A | N/A |
| Family Deductible | $10,000 | $10,000 |
| Primary Care Visit2 | $60 | $60 |
| Specialty Care Visit | $70 | $70 |
| Urgent Care | $120 | $120 |
| Emergency Room | $300 | $300 |
| Lab Tests | 30% | 30% |
| X-Rays | 30% | 30% |
| Generic Rx | $19 | $15 |
| Brand Rx | $50 | $50 |
| In-Patient/Imaging5 | 30% | 30% |
| Ind. MOOP | $6,350 | $6,250 |
| Family MOOP | $12,700 | $12,500 |
Bronze H.S.A |
2014 | 2015 |
| Ind. Med. Deductible | $4,500 | $4,500 |
| Rx Deductible | $0 | $0 |
| Family Deductible3 | $9,000 | $9,000 |
| Primary Care Visit | 40% | 40% |
| Specialty Care Visit | 40% | 40% |
| Urgent Care | 40% | 40% |
| Generic Rx | 40% | 40% |
| Brand Rx | 40% | 40% |
| Lab Tests | 40% | 40% |
| X-Rays | 40% | 40% |
| Emergency Room | 40% | 40% |
| In-Patient/Imaging5 | 40% | 40% |
| Ind. MOOP | $6,350 | $6,250 |
| Family MOOP4 | $12,700 | $12,500 |
Silver 70 |
2014 | 2015 |
| Ind. Med. Deductible | $2,000 | $2,000 |
| Ind. Rx Deductible | $250 | $250 |
| Family Med. Deductible | $4,000 | $4,000 |
| Family Rx Ded. | $500 | $500 |
| Primary Care Visit | $45 | $45 |
| Specialty Care Visit | $65 | $65 |
| Urgent Care | $90 | $90 |
| Emergency Room | $250 | $250 |
| Lab Tests | $45 | $45 |
| X-Rays | $65 | $65 |
| Generic Rx | $19 | $15 |
| Brand Rx | $50 | $50 |
| In-Patient/Imaging5 | 20% | 20% |
| Ind. MOOP | $6,350 | $6,250 |
| Family MOOP | $12,700 | $12,500 |
Silver 73 |
2014 | 2015 |
| Ind. Med. Deductible | $1,500 | $1,600 |
| Ind. Rx Deductible | $250 | $250 |
| Family Med. Deductible | $3,000 | $3,200 |
| Family Rx Deductible | $500 | $500 |
| Primary Care Visit | $40 | $40 |
| Specialty Care Visit | $50 | $50 |
| Urgent Care | $80 | $80 |
| Emergency Room | $250 | $250 |
| Lab Tests | $40 | $40 |
| X-Rays | $50 | $50 |
| Generic Rx | $19 | $15 |
| Brand Rx | $30 | $35 |
| In-Patient/Imaging5 | 20% | 20% |
| Ind. MOOP | $5,200 | $5,200 |
| Family MOOP | $10,400 | $10,400 |
Silver 87 |
2014 | 2015 |
| Ind. Med. Deductible | $500 | $500 |
| Ind. Rx Deductible | $50 | $50 |
| Family Med. Deductible | $1,000 | $1,000 |
| Family Rx Deductible | $100 | $100 |
| Primary Care Visit | $15 | $15 |
| Specialty Care Visit | $20 | $20 |
| Urgent Care | $30 | $30 |
| Emergency Room | $75 | $75 |
| Lab Tests | $15 | $15 |
| X-Rays | $20 | $20 |
| Generic Rx | $5 | $5 |
| Brand Rx | $15 | $15 |
| In-Patient/Imaging5 | 15% | 15% |
| Ind. MOOP | $2,250 | $2,250 |
| Family MOOP | $4,500 | $4,500 |
Silver 94 |
2014 | 2015 |
| Ind. Med. Deductible | $0 | $0 |
| Ind. Rx Deductible | $0 | $0 |
| Family Med. Deductible | $0 | $0 |
| Family Rx Deductible | $0 | $0 |
| Primary Care Visit | $3 | $3 |
| Specialty Care Visit | $5 | $5 |
| Urgent Care | $6 | $6 |
| Emergency Room | $25 | $25 |
| Lab Tests | $3 | $3 |
| X-Rays | $5 | $5 |
| Generic Rx | $3 | $3 |
| Brand Rx | $5 | $5 |
| In-Patient/Imaging5 | 10% | 10% |
| Ind. MOOP | $2,250 | $2,250 |
| Family MOOP | $4,500 | $4,500 |
Gold |
2014 | 2015 |
| Ind. Med. Deductible | $0 | $0 |
| Ind. Rx Deductible | $0 | $0 |
| Family Deductible | $0 | $0 |
| Family Rx Deductible | $0 | $0 |
| Primary Care Visit | $30 | $30 |
| Specialty Care Visit | $50 | $50 |
| Urgent Care | $60 | $60 |
| Emergency Room | $250 | $250 |
| Lab Tests | $30 | $30 |
| X-Rays | $50 | $50 |
| Generic Rx | $19 | $15 |
| Brand Rx | $50 | $50 |
| In-Patient/Imaging5 | 20% | 20% |
| HMO In-Patient | $600/day | $600/day |
| Ind. MOOP | $6,350 | $6,250 |
| Family MOOP | $12,700 | $12,500 |
Platinum |
2014 | 2015 |
| Ind. Med. Deductible | $0 | $0 |
| Ind. Rx Deductible | $0 | $0 |
| Family Deductible | $0 | $0 |
| Family Rx Deducitible | $0 | $0 |
| Primary Care Visit | $20 | $20 |
| Specialty Care Visit | $40 | $40 |
| Urgent Care | $40 | $40 |
| Emergency Room | $150 | $150 |
| Lab Tests | $20 | $20 |
| X-Rays | $40 | $40 |
| Generic Rx | $5 | $5 |
| Brand Rx | $15 | $15 |
| In-Patient/Imaging5 | 10% | 10% |
| HMO In-Patient | $250/day | $250/day |
| Ind. MOOP | $4,000 | $4,000 |
| Family MOOP | $8,000 | $8,000 |
- All preventive office visits are no charge but must be with an in-network.
- All plans will include children’s dental and vision benefits.
- Bold: Coinsurance or copayment apply after the deductible.
- Deductibles, Copayments and Coinsurance may vary by carrier and plan.
- In-Patient/Imaging: high cost infrequent health care services such as an overnight hospital stay requiring surgery.
- MOOP: Maximum Out Of Pocket, once met, health plan covers all benefit costs.
Footnotes
1. Combination Medical and Rx Drug deductible.
2. First 3 visits the deductible is waived.
3. Aggregate deductible. A member family member must first meet the Family Deductible before coinsurance applies.*
4. Aggregate MOOP. A family member must meet the Family MOOP before all benefits are fully covered.*
5. Some HMO plans will apply a flat copayment rate for each day in the hospital up to a maximum. PPO plans apply a coinsurance percentage toward meeting the Individual or Family MOOP.
5. Some HMO plans will apply a flat copayment rate for each day in the hospital up to a maximum. PPO plans apply a coinsurance percentage toward meeting the Individual or Family MOOP.
Sources: 2014 and 2015 Covered California health plan booklets along with the Shop and Compare Tool and certain EOCs for the health plans.
Numbers are subject to change and errors may be possible.