The health plans don’t recognize the invoiced amount of the health care services from out-of-network providers as either accruing toward the deductible or for their cost-sharing of 50% before the maximum out-of-pocket amount is met. The health plans apply a Usual and Customary Rate (UCR) or the Allowable Amount. This limits their responsibility for payment and increases the health plan members costs.
What has not been explained was if the increased Silver plan rates were based on existing Silver plan enrollments or projected enrollments. For those individuals and families who receive very little or no APTC the off-exchange Silver 70 plans will be 8.3% to 27% less expensive. People will naturally enroll in off-exchange Silver plans to save money. There will also be people who downgrade their plans from Silver to Bronze to save money, or, enroll in a Gold or Platinum plan for more benefits at an equal or lower cost of a Silver plan through Covered California. Either way, people will exit Covered California Silver plans in 2018. And since only the Covered California Silver plans have the increased rates, will that generate enough money to subsidize those people left in the enhanced Silver plans?
If you reside in any of the above counties you will be able to keep your EPO plan. If you reside in any other county, and you have an Anthem Blue Cross EPO or HMO plan, through Covered California or off-exchange, you will need to select a new insurance carrier for 2018. The exit of Blue Cross from the individual and family market does not affect employer group health insurance plans or their Medicare Advantage plans.
Access to health care services is not equal in the United States. Your health plan determines the type of care you receive. The health plans in the employer, individual, and Medicaid markets are separate and they are not equal. The ACA moved us in direction of more equality for all residents regardless of the market type of the health plan. Current Republican proposals under President Trump will widen the gap in disparity between group plans and individual plans. We need to move in a direction the guarantees access to the same level of health care services regardless of whether you work for government, a large employer, have your own individual plan, or are awarded Medicaid because of your income. It is time to dismantle the flawed ‘separate but equal’ assumption of health insurance in the United States.
But if you don’t have an account, are trying to help a family member or friend, or are just checking to see if you current mental health provider might be covered in a new health plan, you will have to swim in the sea of confusion for finding the doctor or counselor. Some of the health plans have great online directories and others really suck. Here is an overview of what I learned.
Since the beginning of health care reform under President Obama there has been intense speculation about how the health insurance companies will react when setting rates for the various health plans they offer. Health insurance is not a commodity like wheat, oil, or pork bellies where the market place of buyers and sellers agree upon a price. While competition does impact the rates to a certain degree, health insurance prices are largely determined by the health care services to be covered, the cost of health care services, and the expected claims for those services within a geographical location where the plan is being offered.
The California Department of Health Care released a report confirming that several health plans may have had inaccurate provider directories for their member to search through. The Timely Access Report year 2015 reviewed several different measurements to determine if health plan members could obtain timely access to health care services. The report noted that 13 health plans listed Primary Care Physicians who were not in the health plan’s provider network.
Consumers should be cautious when a health insurance agent wants to bundle a bunch of other products such as life and accident insurance with the Covered California health plan. These agents and marketing organizations are more interested in selling higher commission products such as life, accident, cancer, stroke, heart attack, and dental plans than they are health insurance. They may try to convince a consumer to drop the health plan to a Bronze level so they can sell questionable indemnity plan products as extra protection for the higher deductible.
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.