The biggest complaint I hear from consumers is that most health plans either cover nothing or are loaded up with benefits they don’t need. The extra benefits drive up the rates – Thanks Covered California – and make enrolling in a plan with basic office visit coverage too expensive. Finally, Blue Shield has designed a health plan for the average individual who just wants protection for unexpected office visits without digging into the medical deductible.
The average individual can go years without ever needing to see a doctor for any diagnostic consultation or therapy for a medical condition. This population has no chronic medical conditions, takes no prescription medications, and only visits a doctor when the pain is too unbearable i.e., – I think it is broke. The main purpose of health insurance for this group is asset protection or limiting their exposure to astronomical medical bills.
Unique Bronze Plan That Delivers What Most People Want and Need
Many people want predictable copayments for routine services and are willing to accept a large deductible and maximum out-of-pocket amount for the rare and unexpected hospitalization. Blue Shield of California has come pretty close to designing such a plan with their 2022 Bronze 7500 HMO individual and family plan. Services with a set copayment and not subject to the medical deductible are:
- Primary Care Visit $70
- Specialist Visit $80
- Physician Home Visit $70
- Outpatient Facility Fee $150
- Acupuncture Visit $50
- Chiropractic Visit $20
- Urgent Care Visit $70
- Lab Tests $65
- X-rays $115
- Certain Diagnostic Tests $115
- Outpatient Therapy, Rehabilitation $70
- Tier 1 Generic Drugs $25
The Bronze 7500 has a combined medical and pharmacy deductible of $7,500 for an individual and $15,000 for a family. Once the deductible is met, Tier 2 through Tier 4 drugs either have a set copayment or coinsurance. Health care services subject to the deductible are 50 percent coinsurance after the deductible is met. Once the copayments, deductible, and coinsurance equal $8,350, the health plan covers all in-network services 100 percent.
Bronze 7500 Offered Through Most of California
The Bronze 7500 HMO is not perfect and may not work for many people. First, it is an HMO plan which means you must select a Primary Care Physician and mostly see that PCP for referrals to a specialist. No referral necessary to visit an OB/GYN physician in your medical group network. The Bronze 7500 is only available in 28 counties in California, mostly in the Bay Area, Central Valley, and Southern California.
The second drawback are that the copayments are relatively high compared to a standard Silver plan. One injury or illness that requires multiple office visits, tests, and imaging could quickly cost more than the premium differential of standard Silver plan with lower copayments. Third, the maximum out-of-pocket is higher than a standard Bronze 60 or Bronze HDHP at $8,200 and $7,000 respectively. For comparison, the Silver 70 and Silver 1700 plans each have $8,200 maximum out-of-pocket amounts. For pure asset protection, the standard Bronze and Silver plans are equivalent.
Rates for the Bronze 7500 are Competitive
Finally, these plans are not offered through Covered California with the subsidies. In my opinion, they should be available as a middle ground between the bare bones Bronze plans and the Silver plans. The Bronze 7500 does include pediatric dental and vision benefits. Off-exchange rates are competitive with other Bronze and Silver plans.
Orange County, 40 year old individual
- Bronze HMO 7500 $307.63
- Bronze 60 PPO $396.84
- Silver 70 OE HMO $346.38
Sacramento County, 40 year old individual
- Bronze HMO 7500 $409.22
- Bronze 60 PPO $516.57
- Silver 70 OE HMO $460.76
Bicycle Seats and Prostrate Cancer
A few years ago, I had a prostate cancer scare. I had lots of pain and an elevated PSA of 10. I had multiple visits to the doctor, blood tests, and a referral to a urologist who push an endoscope down my urethra an into my bladder. Under the Bronze 7500, I would have had out-of-pocket copayment costs of approximately $650.
With a standard Bronze plan, they way I calculated it, my costs would have been closer to $1,500 to $2,000. I did not have prostate cancer. I had a bad bike seat. The bike seat, on a new bike I had bought a few months earlier, was irritating my pudendal nerve leading to pain involving the prostate. A new bike seat and change in riding positions solved the pain problems.
I would have been better off with a Silver plan with the lower copayments. However, I rarely go to the doctor. The pudendal pain problem was the first health challenge I had in years. Consequently, I would have saved more money with the Bronze 7500 compared to a Silver 70 over a several year period, even with the increased cost of the mountain bike injury.