The real looming threat is the loss of health plans participating in the IFP market. In 2017 three carriers dominated the market with 72% of the enrollments: Anthem Blue Cross 19%, Blue Shield 25%, Kaiser 28%. With the loss of Blue Cross in the major metropolitan markets such as the Bay Area and Southern California, two carriers, Blue Shield and Kaiser, are likely to command over 60% of the market place in 2018. If one of those two carriers determines that offering IFP plans is just too risky in 2018, it could lead to other carriers such as Health Net, Molina, or Oscar also pulling out of the market.
There a lots of different dental plans off-exchange or outside of Covered California. The number of plans makes comparisons complicated and confusing. Delta Dental and Anthem Blue Cross offer dental plans through Covered California and a variety of different plans off-exchange. The single largest difference between the Covered California plans and the ones offered off-exchange is the 12 month waiting period for major dental work such as extractions, root canals, and crown. The six month waiting period usually applies to minor restorative work such as getting a cavity filled.
Health insurance companies are smarter than your average house cat. They have reams of data about health care claims and demographics. They can forecast, with reasonable confidence, that altering some of the member cost-sharing benefits may reduce their final exposure to pay member claims. It has also been suggested that consumers who purchase health insurance off-exchange, paying the full premium rate with no subsidy, may be more judicious in how they use health care services. In other word, off-exchange consumer mays tend to file fewer health care expense claims. This results in lower rates to the consumer.
Families don’t all have to be with the same carrier either. Some parents have chosen a PPO plan for their children because certain doctors who are treating their children are in-network with the PPO plan. The parents then choose a less expensive HMO plan for themselves. It could be that a family member needs surgery during the next year. That person might opt for a Gold or Platinum plan to reduce out-of-pocket expenses while the other family members hang out in the Bronze or Silver metal tier level.
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.