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Health Plan Market & Benefit Comparison Part I . Presented by Cliff Craig Health Plan Account Manager for Connect for Health Colorado. Key Topics to be Discussed. Review Basic Insurance Terminology Key Things to Consider When Distinguishing Between Carriers & Benefit Coverage

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health plan market benefit comparison part i
Health Plan Market & Benefit Comparison Part I

Presented by Cliff Craig

Health Plan Account Manager for Connect for Health Colorado

key topics to be discussed
Key Topics to be Discussed
  • Review Basic Insurance Terminology
  • Key Things to Consider When Distinguishing Between Carriers & Benefit Coverage
  • Understanding Plan Benefits & Summary of Benefits and Coverage (SBC)
simple terms and definitions
Simple Terms And Definitions
  • Monthly Premium – The monthly amount that you must pay for your health / dental insurance (coverage)
  • Annual Deductible - You need to pay this amount before your plans starts helping you pay for most covered services through coinsurance. You may have to cover some costs that will not count toward this total deductible.
  • Annual Out of Pocket Limit - This is the most you’ll pay for care during a policy period (usually a year) before your plan starts paying 100 percent for most covered services.
  • Copay - A fixed amount (for example, $15) you pay for a medical visit or for medication that is covered under your health plan, usually when you receive the service. This is considered part of your out-of-pocket costs, separate from premiums and deductibles.
  • Coinsurance - After reaching your deductible, you may start paying a percentage of the total cost for certain services. Coinsurance usually reflects the percentage of medical expenses that you are responsible to cover, for dental expenses the percentage reflects what the dental plan will cover.
simple terms and definitions1
Simple Terms And Definitions
  • In Network (Tier 1) –Whatyou pay for covered health care services to providers who are contracted with your health insurance or plan. In-network benefits cost you less than out-of-network benefits.
  • Out of Network – The benefits levels you pay for covered health care services to providers who are NOT contracted with your health insurance or plan. Out of network benefits cost are much higher than In-network benefits.
  • Summary of Benefits and Coverage (SBC) – This document will help consumers better understand the coverage they have and, for the first time, allow them to easily compare different coverage options. It will summarize the key features of the plan or coverage, such as the covered benefits, cost-sharing provisions, and coverage limitations and exceptions. People will receive the summary when shopping for coverage, enrolling in coverage, at each new plan year, and within seven business days of requesting a copy from their health insurance issuer or group health plan.
annual deductible
Annual Deductible
  • You need to pay this amount before your plan starts helping you pay for most covered services through coinsurance.
  • Most plans Copays do not apply and are not dependent on the Deductible.
  • Family Deductibles are normally 2 times the Individual Deductibles.
  • Deductibles accumulate on a calendar year, Jan. 1st to Dec. 31st.
  • Deductibles could or could not apply to the Out-of-Pocket Limit.
  • Once Copays, Coinsurance, Deductible & Out-of-Pocket Limit reach the Maximum Out-of-Pocket limit $6,350 individual / $12,700 family for a calendar year the Plan pays 100%

Sample from a SBC document:

annual out of pocket limit
Annual Out of Pocket Limit
  • This is the most you’ll pay for care during a policy period (usually a year) before your plan starts paying 100 percent for most covered services.
  • Family Out-of-Pocket Limits are normally 2 times the Individual Out-of-Pocket Limits.
  • Out-of-Pocket Limits accumulate on a calendar year, Jan. 1st to Dec. 31st.
  • In the sample below the plan would pay 100% for coinsurance after the $5,200 / $10,400, the member will still pay for copays up to the $6,350 / $12,700 limit
  • Remember once Copays, Coinsurance, Deductible & Out-of-Pocket Limit reach the Maximum Out-of-Pocket limit $6,350 individual / $12,700 family for a calendar year the Plan pays 100%
    • Rx copays & deductibles are included in the Maximum Out-of-Pocket
    • Maximum Out-of-Pocket Limit applies to In-Network services ONLY

Sample from a SBC document:

copay coinsurance
Copay & Coinsurance

Copay

A fixed amount (for example, $15) you pay for a medical visit or for medication that is covered under your health plan, usually when you receive the service. This is considered part of your out-of-pocket costs, separate from premiums and deductibles.

  • There may be separate copays for different services: Primary care, Specialist, Preventive care, Hospitalization, Emergency Room etc…
  • Some plans require that a deductible first be met for some specific services before a copayment applies

Coinsurance

After reaching your deductible, you may start paying a percentage of the total cost for certain services. Coinsurance usually reflects the percentage of medical expenses that you are responsible to cover, for dental expenses the percentage reflects what the dental plan will cover.

allowed amount balance billing
Allowed Amount & Balance Billing

Allowed AmountMaximum amount on which payment is based for covered health care services. This may be called “eligible expense,” “payment allowance” or “negotiated rate.”

Balance BillingWhen a provider bills you for the difference between the provider’s charge and the Allowed Amount. For example, if the provider’s charge is $100 and the allowed amount is $70, the provider may Balance Bill you for the remaining $30. A preferred provider, one that is participating in your insurance company’s provider network, can not Balance Bill you for covered services.

key questions that influence an individual s shopping decisions
Key Questions That Influence An Individual’s Shopping Decisions
  • What is most important to the person who is looking for a plan?
    • Are they currently insured? Happy with your current carrier?
    • Low premium? Low cost-sharing charges?
    • Providers or Hospital?
  • What does their budget allow for health coverage?
    • Is the person eligible for premium credits or cost-sharing reductions?
      • This may make some coverage tiers (i.e., Silver) more attractive.
  • What health care does the person expect to use during the year?
    • Do you have a medical conditions?
    • Are you or any family member attached to seeing a particular physician?
choosing your current carrier
Choosing Your Current Carrier
  • Is your current carrier offering plans on the Exchange?
    • If they wish to stay with their current carrier, now it becomes a search for similar out of pocket cost for accessing benefits.
  • They are currently taking medication, still review the carriers Rx benefit & formulary to confirm the medication is covered at a comfortable out of pocket cost amount.
    • Formulary is to specify particular medications that are approved to be prescribed under a particular insurance policy.
    • A carriers formulary and drug coverage level can change based on plan type
    • Drug coverage levels – Tier 1 Generic, Tier 2 Preferred, Tier 3 Non-Preferred, Tier 4 Specialty Drugs
  • If they have a chronic medical condition and are continuing to receive care from a specific physician or facility, check the carriers provider directory.
    • A carriers networks can change based on plan type.
using the search functions for lower premiums or lower cost sharing
Using the Search Functions for Lower Premiums or Lower Cost-sharing
  • A person can search by:
  • Provider
  • Monthly premium
  • Annual Deductibles
    • Individual
    • Family
  • Annual Out-of-Pocket
    • Individual
    • Family
  • Carrier
  • Coverage Level
    • Metal Tiers
advanced premium tax credit aptc cost sharing reduction csr sample
Advanced Premium Tax Credit (APTC) & Cost Sharing Reduction (CSR) Sample
do you have a medical conditions
Do You Have a Medical Conditions?
  • Preexisting conditions can no longer be used to deny coverage or be used to increase their premium.
    • Do you have a specific physician or facility treating you for this condition?
    • Do you take certain medications to treat the condition?
      • The carriers plan benefit page has a link to their formulary
    • How often do you require testing services? Lab / Radiology ?
are you or a family member attached to a physician
Are You or a Family Member Attached to a Physician?
  • OB/GYN?
    • Primary care physicians
    • Primary care copay
  • Children's Pediatrician?
    • Primary care physicians
    • Primary care copay
  • Specialist?
    • Specialist visit copay
    • A person could have had a heart condition 10 years ago, but continues to see his Cardiologist once a year for a check up
    • Some plans may require a Primary care referral to access a Specialist
  • Hospitals can also play an important role
    • In their neighborhood
    • Easy access
what three factors influence s my premiums your age tobacco use location
What Three Factors influence's my premiums? Your Age, Tobacco Use, Location

Your age

  • Rates from 0 to 20 years have the same rate factor, rates for 21 year old to 65 plus year old the rate factors increase every year

Tobacco Use

  • Most plans (not all) increase their rates for tobacco user
  • Any tobacco use more than 4 times a week over the past 6 months (smoking, electronic cigarettes & chew), but it excludes any tobacco use for religious or ceremonial reasons

Your individual rate is based on zip code & county

  • Colorado has 11 rating areas based on varies counties, determined by the DOI
  • If your coverage is through your employer, the rate is based on the employer’s zip code & county
actual c4hco silver plan sample rates denver market
Actual C4HCO Silver Plan Sample Rates Denver market

Age 20 to 21 = 37% increase

Other ages vary from 1.3% up to 4.5%

Non tobacco to tobacco user 13% increase

Age 21 to 65 has a 67% increase

Anyone over 65 would

receive the same rate

what three factors influence my premiums your age tobacco use location
What Three Factors influence my premiums? Your Age, Tobacco Use, Location

Colorado has 11 rating areas based on varies counties

Rating Area 1 & 2 have the lowest rates & Rating Area 11 the highest (rates average about 40% difference)

Some zip codes will cross multiple counties

actuarial value metal tiers
Actuarial Value & Metal Tiers

What Does Actuarial Value Mean? (Risk sharing between Carrier & members)

  • The actuarial value of a plan tells you what percentage of health care costs that health insurance plan is expected to pay for its beneficiaries. A plan with an actuarial value of 60 percent (Bronze) is expected to pay approximately 60% of the health care costs of its beneficiaries. The plan’s beneficiaries will pay the other 40% of their health care costs in the form of deductibles, coinsurance and copayments.
  • Actuarial value is calculated for the health plan as a whole, not for individual members. So, on average across all of a health plan’s subscribers, the actuarial value describes the percentage of health care expenses that will be paid by the plan. However, the percentage of your health care expenses the plan will pay will vary depending on how you use your health insurance. In general:
    • If you are a LOW health care utilizer and want a plan to cover you for prevention or in case of an emergency – Bronze plans
    • If you are a HIGH healthcare utilizer – Gold or Platinum plans

Metal Tiers

  • Bronze plans 60% / Silver plans 70% / Gold plans 80% / Platinum plans 90%
  • Catastrophic (CYA) plans are for individuals under the age of 30OR get a "hardship exemption" from the Federal Government.
    • Meet all of the requirements applicable to other Qualified Health Plans (QHPs) but that don't cover any benefits other than 3 primary care visits per year before the plan's deductible is met. The premium amount you pay each month for health care is generally lower than for other QHPs, but the out-of-pocket costs for deductibles are generally higher ($6350 / $12700).
cost sharing and metal tiers
Cost-Sharing and Metal Tiers

ACA Precious Metal Tiers

Actuarial value

percentages represent

how much of a typical

population’s medical

spending a health

insurance plan would

cover.

In general, lower

member cost-sharing

and higher premiums

Plan Tier

Actuarial Value

Platinum

90%

Gold

80%

Silver

70%

In general, higher

member cost-sharing

and lower premiums

Bronze

60%

market place plan types
Market Place Plan Types

Health Maintenance Organization (HMO)A type of health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO. It generally won’t cover out-of-network care except in an emergency. An HMO may require you to live or work in its service area to be eligible for coverage. HMOs often provide integrated care and focus on prevention and wellness. (No Out of Network Coverage)

Preferred Provider Organization (PPO)A type of health plan that contracts with medical providers, such as hospitals and doctors, to create a network of participating providers. You pay less if you use providers that belong to the plan’s network. You can use doctors, hospitals and providers outside of the network for an additional cost. (Out of Network Coverage but at Higher Cost-sharing)

Exclusive Provider Organization (EPO)

A more restrictive type of preferred provider organization plan under which employees must use providers from the specified network of physicians and hospitals to receive coverage; there is no coverage for care received from a non-network provider except in an emergency situation. (No Out of Network Coverage)

what applies to maximum out of pocket hmo epo plans
What Applies to Maximum Out-of-Pocket HMO & EPO Plans

Copayments

Rx Deductibles

Rx

Copayments

Deductibles

Coinsurance

Rx

Coinsurance

Maximum

Out-of-Pocket

$6,350 / $12,700

Prevention

what applies to maximum out of pocket hmo epo plans1
What Applies to Maximum Out-of-Pocket HMO & EPO Plans

Deductibles

Copayments

Rx

Copayments

Coinsurance

Out-of-Pocket Limit

Maximum

Out-of-Pocket

$6,350 / $12,700

Prevention

what applies to maximum out of pocket ppo plans
What Applies to Maximum Out-of-Pocket PPO Plans

In Network Services

Out of Network Services

Deductibles

Copayments

Deductibles

Rx

Copayments

Coinsurance

Coinsurance

Out-of-Pocket Max.

Maximum

Out-of-Pocket

$6,350 / $12,700

Prevention

case study of how benefits accumulate for a individual policy
Case Study of How Benefits Accumulate for a Individual Policy

Actual C4HCO HMO Silver Plan

  • Medical Deductible = $2,500 / $5,000 Drug Deductible = $250 Out-of-Pocket Max. = $6,350 / $12,700
  • PCP visit = $30 Copay / Specialist = $50 Copay
  • Prescription Drugs = $15 Generic / $45 (After Ded.) Preferred Brand / 30% (After Ded.) Non-Preferred & Specialty
  • Facilities = 30% Coinsurance (After Ded.) Outpatient / Inpatient Surgery
  • Emergency Care = $75 Copay Urgent care center / $400 Copay Emergency Room / 30% coin. (After Ded.) Ambul.
  • Testing = $300 copay CT/PET Scans, MRIs / 30% coinsurance (After Ded.) X-rays / Lab.

This plan has a single Rx Deductible even for family. That means each family member has a $250 Rx deductible

case study of how benefits accumulate for a catastrophic cya policy
Case Study of How Benefits Accumulate for a Catastrophic (CYA) Policy

Actual C4HCO Catastrophic (CYA) Plan

  • Medical Deductible = $6,350 / $12,700 Out-of-Pocket Max. = $6,350 / $12,700
  • PCP visit = $35 Copay (limit 3 per year) Specialist = 100% Out-of-pocket / Prescription Drugs = 100% Out-of-pocket
  • Outpatient / Inpatient Surgery / Emergency Care / CT/PET Scans, MRIs / X-rays / Lab. = 100% Out-of-pocket

All plans cover Prevention

At no cost

All Catastrophic plans cover 3 PCP visits per year not subject to the Deductible

plan documents can be used at decision points
Plan Documents Can Be Used at Decision Points

Evidence of Coverage, Policy,

Summary of Benefits: It’s the members

Contract with the carrier

(about 80 plus pages) varies by carrier

English only

Summary of Benefits and Coverage, is a summary

of benefits (not a binding contract), standard benefit

Layout (9 pages) English & Spanish

Company Profile: Standard document

Covers – Company at a glance, Medical

Loss Ratio, Unique Offerings & Programs,

Awards & Recognition,& In the Community.

English & Spanish

Quality Overview: Standard Document Covers –

Accreditations, Consumer Complaints, How the plan

makes members healthier / works with providers /

examples of innovative approaches, Quality Ratings.

English & Spanish

Carrier Marketing materials:

Not Standard, Varies by carrier

English & Spanish

scenario one
Scenario One

33 year old single male, annual income $50,000 per year

  • No previous health issues, but a tobacco user, averages $150 a year in medical expenses
  • His primary concern is meeting the new regulation & not having a tax penalty

What is he eligible for?

  • APTC or CSR? NO
  • Catastrophic plans? NO

Plans that meet his decision criteria,

  • Actual C4HCO Bronze HSA ($200.73)
    • Ded $5000 / OOP $6350, OV 30% (After Ded), Rx 30% (After Ded)
  • Actual C4HCO Bronze HMO (227.65)
    • Ded $6300 / OOP $6300, OV No Charge (After Ded), Rx No Charge (After Ded)
  • Actual C4HCO Gold HMO ($297.11)
    • Ded $1600 / OOP $500, OV $15 / $25 copays, Rx $10 / $35 / $60 copays
scenario two
Scenario Two

28 year old single female, annual income $22,000 per year

  • Previous health issues, averages $5500 a year in medical expenses
  • Her primary concern is accessing medical services with low OOP expenses

What is she eligible for?

  • APTC or CSR? APTC = $104.65 per month / CSR 87%
  • Catastrophic plans? Yes

Plans that meet her decision criteria,

  • Actual C4HCO EPO Catastrophic ($143.78) + Medical expenses ($5350) = ($7075)
    • Ded $6350 / OOP $6350, OV $50 for 3 100% (After Ded), Rx No Charge (After Ded)
  • Actual C4HCO Bronze HSA ($53.72) + Medical expenses ($5150) = ($5795)
    • Ded$5000/OOP$6350,OV30%(After Ded)Rx 30%(After Ded)Facility30%(After Ded)
  • Actual C4HCO Silver HMO ($227.65) + Medical expenses ($2250) = ($4982)
    • Ded $0 / OOP $2250, OV $15/$25 copay, Rx $15/$45/20% Facility 20% (After Ded)
scenario three
Scenario Three

45 year old single male, Native American, annual income $25,000 per year

  • Previous health issues, averages $5500 a year in medical expenses
  • His concern is accessing medical services with low OOP expenses & low premium?
  • APTC or CSR? APTC = $129.60 CSR = 73%
  • Native American? Yes
  • Catastrophic plans? No

Plans that meet his decision criteria,

  • Actual C4HCO Bronze HMO ($92.75)
    • Ded $0 / OOP $0, OV 0%, Rx 0%
  • Actual C4HCO Silver HMO ($144.07)
    • Ded $0 / OOP $0, OV No Charge (After Ded), Rx No Charge (After Ded)
  • Actual C4HCO Gold HMO ($182.55)
    • Ded $0 / OOP $0, OV $0 / $0 copays, Rx $0 / $0 / $0 copays
key takeaways considerations
Key Takeaways & Considerations

Consider Potential

Medical Expenses

Provider networks

Premium isn’t the only consideration in cost

Find the Right Mix

Premium

Plus

Out-of-Pocket

Medical Expenses