Plan Design and Plan Selection
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- Kathryn Shelton
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1 Plan Design and Plan Selection Sarah Lueck and Dave Chandra Center on Budget and Policy Priorities October 30, 2014
2 Elements of Plan Design
3 Premiums vs Cost-Sharing Charges 3 Premiums The monthly cost a person pays for a health plan Cost-Sharing Charges The charges a person pays as he or she uses benefits covered by a health plan
4 Basic Elements of Marketplace Plans 4 Covered Benefits Essential Health Benefits, including preventive services Additional benefits possible Provider Network Insurers contract with physicians, hospitals, and other professionals to provide services to plan enrollees May be broad (with a greater number of providers) or narrow Plan may or may not provide coverage outside its network
5 Cost-Sharing Charges
6 Types of Cost-Sharing Charges 6 Deductible Enrollee must pay the deductible before the plan begins to pay for most benefits Set on a yearly basis Copayments Dollar amount for an item or service that enrollees must pay Coinsurance Percentage of the cost of an item or service that enrollees must pay
7 Maximum Out-of-Pocket Limit (OOP) 7 Puts a cap on what the enrollee pays in cost-sharing charges each year Set on a yearly basis Applies to in-network services, not out-of-network care 2015 maximum amounts $6,600 for an individual (up from $6,350) $13,200 for a family (up from $12,700) Lower maximum amounts for people with cost-sharing reduction plans in 2015 $2,250 individual/$4,500 family up to 200% FPL $5,200 individual/$10,400 family at % FPL OOP limit is not the amount that an enrollee must spend each year
8 covered Cost-Sharing and the Metal Tiers 8 Platinum Gold Silver Bronze METAL LEVEL PLAN TIERS QHPs must provide plan designs consistent with actuarial values Catastrophic coverage 90% actuarial value 80% actuarial value 70% actuarial value 60% actuarial value High deductible health plan available for individuals up to age 30 and some individuals exempted from the individual responsibility requirement. Cannot be used with the premium tax credit. Actuarial value is an estimate of how much of a typical population s health care costs an insurance plan will cover. It is used to compare the generosity of different health plans. It considers the health care use of an overall population and does not necessarily reflect the actual cost-sharing experience of an individual. Premiums paid by consumer
9 Example: Actuarial Value Guides Cost-Sharing Charges 9 Plan A: Bronze Plan B: Bronze Plan C: Silver Plan D: Silver Plan E: Gold Actuarial Value 60% AV 60% AV 70% AV 70% AV 80% AV Deductible (individual) $4,000 $2,500 $1,500 $2,000 $750 Maximum OOP limit (individual) $6,350 $6,350 $4,000 $5,000 $2,500 Inpatient hospital 30% 50% 20% 30% 10% Primary Care visit $60 (for first 2) 50% 20% $20 $20
10 How Cost-Sharing Works 10 Jane s Plan: Annual Deductible: $4,000 Cost-Sharing (coinsurance): Enrollee pays 30% Out-of-Pocket (OOP) Limit: $6,350 Meets $4,000 deductible Reaches $6,350 OOP limit Plan Pays Jane Pays Plan Pays Jane Pays Plan Pays Jane Pays Jan 1 Before Jane meets her $4,000 deductible, her plan doesn t cover any of her costs (except for preventive care). Once Jane meets the deductible, the plan shares in her costs by covering 70% of covered items and services. Jane pays the remaining 30% coinsurance. Jane reaches the $6,350 OOP limit. Now the plan will pay the full cost of any additional in-network services she receives during the rest of the year. Dec 31
11 Individual and Family Cost-Sharing Charges Differ 11 Jane: Plan Details The Rogers Family: Plan Details $4,000 deductible $6,350 OOP limit Primary care $60 Inpatient 30% Generic drugs $5 $8,000 deductible $12,700 OOP limit Primary care $60 Inpatient 30% Generic drugs $5
12 More to Know about Cost-Sharing Charges 12 Some services may be exempt from the deductible Examples: Coverage of 2 physician visits for a copayment; coverage of generic drugs with a copayment even when enrollee has not reached the deductible Some benefits may have a separate deductible Example: Prescription drugs For families, the deductible and out-of-pocket limit may apply on a family basis or per-member. Family (aggregate) cost-sharing: All family members expenses are pooled toward a combined deductible and out-of-pocket limit. Per-member (embedded) cost-sharing: In addition to a family deductible and out-of-pocket limit, smaller individual deductibles and out-of-pocket limits apply to each family member.
13 Example: Aggregate Family Cost-Sharing 13 Plan Deductible (family): $8,000 Cost-Sharing (coinsurance): Family pays 30% Family Out-of-Pocket (OOP) Limit: $12,700 William: $20,000 total health expenses 30% cost-sharing $5,000 (pays $5,000) Paula: $10,000 total expenses $3,000 (pays $3,000) Sammy: $500 total expenses Reach $8,000 family deductible $500 (pays $150) $7,000 (pays $2,100) $8,167 (pays $2,450) Reach $12,700 family OOP limit $6,833 (pays $0) Plan pays 100% Jan 1 Dec 31
14 Example: Embedded Family Cost-Sharing 14 Plan Deductible (family): $8,000 Cost-Sharing: Family pays 30% OOP Limit (family): $12,700 Individual Deductible: $4,000 Individual OOP Limit: $6,350 William: $20,000 total expenses $4,000 (pays $4,000) Paula: $10,000 total expenses Sammy: $500 total expenses Jan 1 $4,000 individual deductible $3,000 (pays $3,000) $1,000 (pays $300) 30% cost-sharing (William only) $200 (pays $200) $500 (pays $500) Reach $8,000 family deductible 30% family cost-sharing $6,834 (pays $2,050) $6,800 (pays $2,040) $6,350 individual OOP limit $8,166 (pays $0) Plan pays 100% (William only) The Rogers spend $12,090 out-of-pocket. They don t reach the family OOP limit of $12,700. Dec 31
15 Cost-Sharing Reductions
16 What are Cost-Sharing Reductions? 16 A federal benefit that reduces the out-of-pocket charges an enrollee pays for medical care covered by the plan People with income up to 250% FPL are eligible Must enroll in a silver plan through the Health Insurance Marketplace 3 levels of cost-sharing reduction plans based on income
17 Sample Cost-Sharing Reduction Plans 17 Standard Silver (No CSR) CSR Plan for % FPL CSR Plan for % FPL CSR Plan for up to 150% FPL Actuarial Value 70% AV 73% AV 87% AV 94% AV Deductible (individual) $2,000 $2,000 $550 $175 Maximum OOP limit (individual) $5,000 $4,000 $1,100 $350 Inpatient hospital 30% 30% 20% 20% Primary Care visit $20 $20 $10 $10
18 Other Plan Elements to Consider When Evaluating Plan Design
19 Other Plan Elements to Consider: 19 Provider Network Prescription Drug Formulary Differences in Covered Benefits Pediatric dental included? Benefits covered in addition to the Essential Health Benefits? Limits (such as a visit limit) on specific services?
20 Cost-Sharing Differs for Care Provided In and Out of Network Plans may have separate deductibles and other cost-sharing amounts for out-of-network and in-network services 20 Annual Deductible Annual OOP Limit Hospital Admission Primary Care Visit Specialist Visit Plan A Plan B In-Network $4,000 $6,350 30% $60 30% Out-of-Network $8,000 $12,700 50% 50% 50% In-Network $4,000 $6,350 30% $60 30% Out-of-Network N/A N/A N/A N/A N/A Tier I $2,000 $5,000 30% $20 $40 Plan C Tier II $4,000 $6,350 50% $40 $60 Tier III $8,000 $12,700 50% 50% 50%
21 In-Network vs. Out-of-Network Care 21 Annual Deductible Annual OOP Limit Inpatient Hospital Primary Care Visit In-Network $5,000 $6,350 $1,500/ admission $25 Out-of-Network $10,000 None 50% 50% Network Physician Doctor s Bill: $200 Plan Allowed Amount: $100 Out-of- Network Physician Doctor s Bill: $200 Plan Allowed Amount: $100 Plan pays: $75 Plan Pays: $50 Patient pays: $25 copayment Counts toward OOP Limit Patient pays: $150 (50% + $100) Does not count toward OOP limit
22 Evaluating Plans Based on Drug Formulary 22 Chuck regularly takes three prescription drugs. Total monthly prices are: $100 for Drug X $200 for Drug Y $300 for Drug Z Health Plan A Tier 1: $10 Tier 2: 20% Health Plan B Tier 1: $15 Tier 2: $40 Drug X Drug Y Drug Y Drug Z Tier 3: 30% Tier 3: 50% Drug X Chuck s monthly cost: $360 ($60 coinsurance + full cost of Drug Z) Chuck s monthly cost: $130 ($80 in copays + $50 coinsurance)
23 Evaluating Plans Based on Drug Formulary 23 Does the plan cover all of the drugs a person expects to need? What cost-sharing charges will the consumer pay for his drugs under the plan?
24 Evaluating Differences Covered Benefits 24 Plan 1 Plan 2 Plan 3 Home Health Aide Limit 60 days/year No limit listed Limit 60 days/year Hospice service No limit listed Limit 5 days for respite care/15 days combined for respite and continuous Limit 20 days for respite care Outpatient physical, occupational, speech, and physiotherapy Combined 45-session limit No limit listed Combined 45-session limit Added benefits Chiropractic care Chiropractic care Chiropractic care Non-emergency care when traveling outside the U.S. Bariatric surgery
25 Evaluating Plans Based on Scope of Benefits 25 Chuck expects to need 40 visits of physical therapy during the year, at a charge of $100 each. Health Plan A $25 copay 25 visits per year Health Plan B $25 copay 40 visits per year Patient pays: $2,125 ($625 in copays + $1,500 for uncovered visits) Patient pays: $1,000 (40 x $25 copay)
26 Evaluating Plan Design: Key Questions 26 Is the person eligible for premium credits or cost-sharing reductions? This may make some coverage tiers (i.e., silver) more attractive than others. What is most important to the person who is looking for a plan? Low premium? Low cost-sharing charges? What health care does the person expect to use during the year? Looking for plans that cover specific providers, medications, etc., may be important. Expected health needs may impact whether a person prefers more upfront cost sharing (high deductible) or more as-yougo cost-sharing (copayments).
27 Assisting Consumers in Plan Selection
28 Scenario 1: Joe and Danielle Fraser 28 Joe Danielle Residence Miami-Dade County, FL Age Income $24,000 $17,000 Employer coverage? no no Insurance status uninsured uninsured
29 APTC Calculation for Joe and Danielle 29 Combined Income: $41,000 (264% FPL) Benchmark plan (2 nd Lowest Silver) cost: $5,964 Expected contribution: 8.47% of income or $3,480 Premium credit: $2,484 ($207/month) APTC Expected Contribution (8.47% of income) Plan Cost: $5,964
30 Scenario 1: Joe and Danielle Fraser 30 Do you want to use all of your $124 premium tax credit each month? Applicants (age): Joe (33) $180 Danielle (31) $180 $0/month $207/month FPL: 264% $100/month x 12 months = $1200 towards monthly premiums + $288 on your Federal tax return APTC: $207/month $1,488 total premium tax credit
31 Scenario 1: Joe and Danielle Fraser 31 Applicants (age): Joe (33) Danielle (31) FPL: 264% APTC: $207/month
32 Scenario 1: Joe and Danielle Fraser 32 $207/month Applicants (age): Joe (33) $159/mo. $12,600/yr $12,600/yr Danielle (31) FPL: 264% APTC: $207/month $177/mo. $12,700/yr $12,700/yr
33 Scenario 1: Joe and Danielle Fraser 33 All health plans (137) 48 health plans Applicants (age): Joe (33) Danielle (31) FPL: 264% APTC: $207/month
34 Scenario 1: Joe and Danielle Fraser 34 Applicants (age): Joe (33) Danielle (31) FPL: 264% APTC: $207/month
35 Scenario 1: Joe and Danielle Fraser 35 Applicants (age): Joe (33) Danielle (31) FPL: 264% APTC: $207/month
36 2014 Marketplace Plan Options 36 Scenario 1: Joe and Danielle Fraser Carrier Plan Name Metal Tier Monthly Premium Deductible OOP Max 1 Coventry Health Care Bronze Deductible Only HMO HSA Bronze $159 $12,600 $12,600 2 Preferred Medical Plan Bronze Select AX Dade Bronze $177 $12,700 $12,700 3 Coventry Health Care Bronze $10 Copay HMO Carelink Bronze $184 $11,200 $12,700 4 Humana Medical Plan Humana Connect Bronze 6300/6300 Bronze $239 $12,600 $12,600 5 Preferred Medical Plan Silver Deluxe AX Dade Silver $248 $8,400 $12,700 6 Preferred Medical Plan Bronze Select BX Dade Bronze $269 $12,700 $12,700 7 Humana Medical Plan Humana Connect Bronze 4850/6350 Bronze $273 $9,700 12,700 8 Aetna Aetna Advantage 6350 Bronze $275 $12,700 $12,700 9 Aetna Aetna AdvantagePlus 5500 PD Bronze $286 $11,000 $12, Coventry Health care Silver $10 Copay HMO Carelink Silver $290 $7,500 $12, Coventry Health care Gold $5 Copay HMO Carelink Gold $332 $3,500 $10,000
37 Plan Options: Joe and Danielle 37 Applicants (age): Joe (33) FPL: 264% Danielle (31) APTC: $207/month Coventry Preferred Preferred Coventry Deductible Only HMO Carelink Bronze Select AX Dade Silver Deluxe AX Dade $5 Copay HMO Carelink Bronze Bronze Silver Gold Monthly Premium $159 $177 $248 $332 Deductible (medical/drug) $12,600 (comb.) $12,700 (comb.) $8400/$1600 $3,500/$250 Maximum OOP limit $12,600 $12,700 $12,700 $10,000
38 Plan Options: Joe and Danielle 38 Applicants (age): Joe (33) FPL: 264% Danielle (31) APTC: $207/month Coventry Preferred Preferred Coventry Deductible Only HMO Carelink Bronze Select AX Dade Silver Deluxe AX Dade $5 Copay HMO Carelink Bronze Bronze Silver Gold Monthly Premium $159 $177 $248 $332 Deductible (medical/drug) $12,600 (comb.) $12,700 (comb.) $8400/$1600 $3,500/$250 Maximum OOP limit $12,600 $12,700 $12,700 $10,000 Primary Care Office Visit Specialist Office Visit Inpatient hospital Rx (generic/brand)
39 Plan Options: Joe and Danielle 39 Applicants (age): Joe (33) FPL: 264% Danielle (31) APTC: $207/month
40 Plan Options: Joe and Danielle 40 Applicants (age): Joe (33) FPL: 264% Danielle (31) APTC: $207/month Coventry Health Care of Florida Bronze Deductible Only HMO HSA Eligible Carelink $159/mo. $12,600/yr $12,600/yr
41 Summary of Benefits and Coverage 41
42 Summary of Benefits and Coverage 42
43 Summary of Benefits and Coverage 43
44 Plan Options: Joe and Danielle 44 Applicants (age): Joe (33) FPL: 264% Danielle (31) APTC: $207/month Health Issues: Joe: asthma, torn knee ligament Coventry Preferred Preferred Coventry Deductible Only HMO Carelink Bronze Select AX Dade Silver Deluxe AX Dade $5 Copay HMO Carelink Bronze Bronze Silver Gold Monthly Premium $159 $177 $248 $332 Deductible (medical/drug) $12,600 (comb.) $12,700 (comb.) $8400/$1600 $3,500/$250 Maximum OOP limit $12,600 $12,700 $12,700 $10,000 Primary Care Office Visit $0 after ded. $30 $20 $5 Specialist Office Visit $0 after ded. $0 after ded. $50 $50 Inpatient hospital $0 after ded. $0 after ded. $300/day 20% after ded. Rx (generic/brand) $0 after ded. $20/$0 after ded. $10/$60 after ded. $5/$30 after ded.
45 Plan Options: Joe and Danielle 45 Applicants (age): Joe (33) FPL: 264% Danielle (31) APTC: $207/month Health Issues: Joe: asthma, torn knee ligament Coventry Preferred Preferred Coventry Deductible Only HMO Carelink Bronze Select AX Dade Silver Deluxe AX Dade $5 Copay HMO Carelink Bronze Bronze Silver Gold Monthly Premium $159 $177 $248 $332 Deductible (medical/drug) $12,600 (comb.) $12,700 (comb.) $8400/$1600 $3,500/$250 Maximum OOP limit $12,600 $12,700 $12,700 $10,000 Primary Care Office Visit $0 after ded. $30 $20 $5 Specialist Office Visit $0 after ded. $0 after ded. $50 $50 Inpatient hospital $0 after ded. $0 after ded. $300/day 20% after ded. Rx (generic/brand) $0 after ded. $20/$0 after ded. $10/$60 after ded. $5/$30 after ded. Asthma prescription covered? # of orthopedic surgeons Ob/Gyn in network? (# in network)
46 Prescription Drug Search: Coventry Health Care of Florida 46
47 Prescription Drug Search: Coventry Health Care of Florida 47
48 Prescription Drug Search: Coventry Health Care of Florida 48
49 Prescription Drug Search: Preferred Medical Plan 49
50 Prescription Drug Search: Preferred Medical Plan 50
51 Plan Options: Joe and Danielle 51 Applicants (age): Joe (33) FPL: 264% Danielle (31) APTC: $207/month Health Issues: Joe: asthma, torn knee ligament Coventry Preferred Preferred Coventry Deductible Only HMO Carelink Bronze Select AX Dade Silver Deluxe AX Dade $5 Copay HMO Carelink Bronze Bronze Silver Gold Monthly Premium $159 $177 $248 $332 Deductible (medical/drug) $12,600 (comb.) $12,700 (comb.) $8400/$1600 $3,500/$250 Maximum OOP limit $12,600 $12,700 $12,700 $10,000 Primary Care Office Visit $0 after ded. $30 $20 $5 Specialist Office Visit $0 after ded. $0 after ded. $50 $50 Inpatient hospital $0 after ded. $0 after ded. $300/day 20% after ded. Rx (generic/brand) $0 after ded. $20/$0 after ded. $10/$60 after ded. $5/$30 after ded. Asthma prescription covered? # of orthopedic surgeons Ob/Gyn in network? (# in network) yes (Tier 3) yes (Specialty) yes (Specialty) yes (Tier 3)
52 Provider Search: Coventry Health Care of Florida 52
53 Provider Search: Coventry Health Care of Florida 53
54 Provider Search: Coventry Health Care of Florida 54
55 Provider Search: Coventry Health Care of Florida 55
56 Provider Search: Preferred Medical Plan 56
57 Provider Search: Preferred Medical Plan 57
58 Plan Options: Joe and Danielle 58 Applicants (age): Joe (33) FPL: 264% Danielle (31) APTC: $207/month Health Issues: Joe: asthma, torn knee ligament Coventry Preferred Preferred Coventry Deductible Only HMO Carelink Bronze Select AX Dade Silver Deluxe AX Dade $5 Copay HMO Carelink Bronze Bronze Silver Gold Monthly Premium $159 $177 $248 $332 Deductible (medical/drug) $12,600 (comb.) $12,700 (comb.) $8400/$1600 $3,500/$250 Maximum OOP limit $12,600 $12,700 $12,700 $10,000 Primary Care Office Visit $0 after ded. $30 $20 $5 Specialist Office Visit $0 after ded. $0 after ded. $50 $50 Inpatient hospital $0 after ded. $0 after ded. $300/day 20% after ded. Rx (generic/brand) $0 after ded. $20/$0 after ded. $10/$60 after ded. $5/$30 after ded. Asthma prescription covered? # of orthopedic surgeons Ob/Gyn in network? (# in network) yes (Tier 3) yes (Specialty) yes (Specialty) yes (Tier 3) 29 (within 20 miles) 17 (in county) 17 (in county) 29 (within 20 miles)
59 Plan Options: Joe and Danielle 59 Applicants (age): Joe (33) FPL: 264% Danielle (31) APTC: $207/month Health Issues: Joe: asthma, torn knee ligament Coventry Preferred Preferred Coventry Deductible Only HMO Carelink Bronze Select AX Dade Silver Deluxe AX Dade $5 Copay HMO Carelink Bronze Bronze Silver Gold Monthly Premium $159 $177 $248 $332 Deductible (medical/drug) $12,600 (comb.) $12,700 (comb.) $8400/$1600 $3,500/$250 Maximum OOP limit $12,600 $12,700 $12,700 $10,000 Primary Care Office Visit $0 after ded. $30 $20 $5 Specialist Office Visit $0 after ded. $0 after ded. $50 $50 Inpatient hospital $0 after ded. $0 after ded. $300/day 20% after ded. Rx (generic/brand) $0 after ded. $20/$0 after ded. $10/$60 after ded. $5/$30 after ded. Asthma prescription covered? # of orthopedic surgeons yes (Tier 3) yes (Specialty) yes (Specialty) yes (Tier 3) 29 (within 20 miles) 17 (in county) 17 (in county) 29 (within 20 miles) Ob/Gyn in network? (# in network) yes* (63 in 20 miles) no* (7 in county) no* (7 in county) yes* (63 in 20 miles) * data not based on actual plan information, are fictitious values used for example purposes only
60 Identify Consumers Priorities for Insurance 60 Cheapest monthly payment? Manageable deductible? Low co-pays/co-insurance? Prescription drug covered? Doctor in network?
61 *Jennifer can be claimed as a tax dependent as a qualifying relative because she is receives more than half of her support from her parents and makes less than $3,950 Scenario 2: The Green Family 61 Rosa Dan Jennifer* Kristy Cara Residence Susquehanna County, PA Age Income $24,000 $19,000 $0 $0 $0 Employer coverage no no no no no Insurance status uninsured uninsured uninsured on Medicaid on Medicaid
62 Scenario 2: The Green Family 62 Applicants (age): Rosa (43) Dan (43) Jennifer (20) FPL: APTC: 154% (CSR 87%) $422/month
63 2014 Marketplace Plan Options 63 Scenario 2: The Green Family Carrier Plan Name Metal Tier Monthly Premium Deductible OOP Max 1 Blue Cross of NE PA myblue Access LP $4,500 Bronze $8 $9,000 $12,700 2 Geisinger Health Plan Marketplace Solutions 13 (POS) Bronze $124 $12,000 $12,500 3 Geisinger Health Plan Marketplace Solutions 12 (POS) Bronze $124 $8,000 $12,700 4 Geisinger Health Plan Marketplace Direct 13 (PPO) Bronze $144 $12,000 $12,500 5 Geisinger Health Plan Marketplace Direct 12 (PPO) Bronze $144 $8,000 $12,700 6 Geisinger Health Plan Marketplace Solutions 10 (POS) Silver $148 $400 $4,500 7 Blue Cross of NE PA mybluecare Silver $154 $800 $1,000 8 Geisinger Health Plan Marketplace Extra 3 (POS) Silver $157 $350 $4,500 9 Geisinger Health Plan Marketplace Solutions 11 (POS) Silver $159 $300 $4, Blue Cross of NE PA myblue Choice LP $5,500 Bronze $164 $11,000 $12,000
64 Plan Options: The Green Family 64 Applicants (age): Rosa (43) Dan (43) FPL: 154% (CSR 87%) Jennifer (20) APTC: $442/month Blue Cross Geisinger Geisinger Blue Cross myblue Access LP $4,500 Marketplace Solutions 12 Marketplace Solutions 10 mybluecare PPO Bronze Bronze Silver CSR 87% Silver CSR 87% Monthly Premium $8 $124 $148 $154 Deductible (medical/drug) $9,000 (comb.) $12,000 (comb.) $400 (comb.) $800/$0 Maximum OOP limit $12,700 $12,500 $4,500 $1,000
65 Plan Options: The Green Family 65 Applicants (age): Rosa (43) Dan (43) FPL: 154% (CSR 87%) Jennifer (20) APTC: $442/month Health Issues: Rosa (hypertension, family history of cancer) Blue Cross Geisinger Geisinger Blue Cross myblue Access LP $4,500 Marketplace Solutions 12 Marketplace Solutions 10 mybluecare PPO Bronze Bronze Silver CSR 87% Silver CSR 87% Monthly Premium $8 $124 $148 $154 Deductible (medical/drug) $9,000 (comb.) $12,000 (comb.) $400 (comb.) $800/$0 Maximum OOP limit $12,700 $12,500 $4,500 $1,000 Primary Care Office Visit 20% after ded. $0 after ded. $0 after ded. $15 Specialist Office Visit 20% after ded. $0 after ded. $0 after ded. $40 Inpatient hospital 20% after ded. $0 after ded. $0 after ded. 10% after ded. Rx (generic/brand) $25/$50 after ded. $3/$60 after ded. $3/$30 after ded. $30/$90
66 Plan Options: The Green Family 66 Applicants (age): Rosa (43) Dan (43) FPL: 154% (CSR 87%) Jennifer (20) APTC: $442/month Health Issues: Rosa (hypertension, family history of cancer) Blue Cross Geisinger Geisinger Blue Cross myblue Access LP $4,500 Marketplace Solutions 12 Marketplace Solutions 10 mybluecare PPO Bronze Bronze Silver CSR 87% Silver CSR 87% Monthly Premium $8 $124 $148 $154 Deductible (medical/drug) $9,000 (comb.) $12,000 (comb.) $400 (comb.) $800/$0 Maximum OOP limit $12,700 $12,500 $4,500 $1,000 Primary Care Office Visit 20% after ded. $0 after ded. $0 after ded. $15 Specialist Office Visit 20% after ded. $0 after ded. $0 after ded. $40 Inpatient hospital 20% after ded. $0 after ded. $0 after ded. 10% after ded. Rx (generic/brand) $25/$50 after ded. $3/$60 after ded. $3/$30 after ded. $30/$90 # of Spanish speaking PCPs Rosa s cardiologist in network? Size of network 4 (within 25 miles) 5 (within 20 miles) 5 (within 20 miles) 4 (within 25 miles)
67 Plan Options: The Green Family 67 Applicants (age): Rosa (43) Dan (43) FPL: 154% (CSR 87%) Jennifer (20) APTC: $442/month Health Issues: Rosa (hypertension, family history of cancer) Blue Cross Geisinger Geisinger Blue Cross myblue Access LP $4,500 Marketplace Solutions 12 Marketplace Solutions 10 mybluecare PPO Bronze Bronze Silver CSR 87% Silver CSR 87% Monthly Premium $8 $124 $148 $154 Deductible (medical/drug) $9,000 (comb.) $12,000 (comb.) $400 (comb.) $800/$0 Maximum OOP limit $12,700 $12,500 $4,500 $1,000 Primary Care Office Visit 20% after ded. $0 after ded. $0 after ded. $15 Specialist Office Visit 20% after ded. $0 after ded. $0 after ded. $40 Inpatient hospital 20% after ded. $0 after ded. $0 after ded. 10% after ded. Rx (generic/brand) $25/$50 after ded. $3/$60 after ded. $3/$30 after ded. $30/$90 # of Spanish speaking PCPs Rosa s cardiologist in network? Size of network 4 (within 25 miles) 5 (within 20 miles) 5 (within 20 miles) 4 (within 25 miles) yes* no* no* yes* * data not based on actual plan information, are fictitious values used for example purposes only
68 Plan Options: The Green Family 68 Applicants (age): Rosa (43) Dan (43) FPL: 154% (CSR 87%) Jennifer (20) APTC: $442/month Health Issues: Rosa (hypertension, family history of cancer) Blue Cross Geisinger Geisinger Blue Cross myblue Access LP $4,500 Marketplace Solutions 12 Marketplace Solutions 10 mybluecare PPO Bronze Bronze Silver CSR 87% Silver CSR 87% Monthly Premium $8 $124 $148 $154 Deductible (medical/drug) $9,000 (comb.) $12,000 (comb.) $400 (comb.) $800/$0 Maximum OOP limit $12,700 $12,500 $4,500 $1,000 Primary Care Office Visit 20% after ded. $0 after ded. $0 after ded. $15 Specialist Office Visit 20% after ded. $0 after ded. $0 after ded. $40 Inpatient hospital 20% after ded. $0 after ded. $0 after ded. 10% after ded. Rx (generic/brand) $25/$50 after ded. $3/$60 after ded. $3/$30 after ded. $30/$90 # of Spanish speaking PCPs Rosa s cardiologist in network? Size of network 4 (within 25 miles) 5 (within 20 miles) 5 (within 20 miles) 4 (within 25 miles) yes* no* no* yes* narrow* medium* medium* broad* * data not based on actual plan information, are fictitious values used for example purposes only
69 Plan Options: The Green Family 69 Applicants (age): Rosa (43) Dan (43) FPL: 154% (CSR 87%) Jennifer (20) APTC: $442/month Health Issues: Blue Cross Rosa (hypertension, family history of cancer) Geisinger myblue Access LP $4,500 Annual Cost Marketplace Solutions 10 Bronze Silver CSR 87% Monthly Premium $8 $96 $148 Deductible (medical/drug) $9,000 (comb.) $4,340 $400 (comb.) Maximum OOP limit $12,700 $4,500 Primary Care Office Visit 20% after ded. $0 after ded. Specialist Office Visit 20% after ded. $0 after ded. Inpatient hospital 20% after ded. $0 after ded. Rx (generic/brand) $25/$50 after ded. $3/$30 after ded. $4,436 Annual Cost $1,776 $400 $0 $0 $18 $2,194 Health Emergency: hospitalization ($3,500 bill), 3 specialist follow up visits ($200/visit), generic prescription drug for 6 months ($40/month retail)
70 Identify Consumers Priorities for Insurance 70 Cheapest monthly payment? Manageable deductible? Low co-pays/co-insurance? Prescription drug covered? Doctor in network? Language spoken by providers? Size and proximity of network? Lowest overall annual cost (premiums + anticipated costsharing)
71 Scenario 3: John (Renewing Consumer) 71 Residence for 2014 Arlington County, VA for 2015 Arlington County, VA Age 28 Income $34, $35,360 Employer coverage No No FPL 296% APTC $0* 303% $0* Insurance status Enrolled in a QHP Renewing in a QHP *Despite John s income being between 100% FPL and 400% FPL, the second lowest silver plan in John s area is cheaper than his expected contribution per the APTC calculation, therefore, he will not receive any APTC.
72 2014 Marketplace Plan Options (December 2013) 72 Scenario 3: Joe (renewing consumer) Carrier Plan Name Metal Tier Monthly Premium Deductible OOP Max 1 CareFirst BlueChoice Inc BlueChoice Young Adult $6,350 Catastrophic $129 $6,350 $6,350 2 Innovation Health IH Basic Catastrophic $134 $6,350 $6,350 3 CareFirst BlueChoice Inc BlueChoice HSA Bronze $6,000 Bronze $150 $6,000 $6,000 4 CareFirst BlueChoice Inc BlueChoice HSA Bronze $4,000 Bronze $157 $4,000 $6,350 5 Innovation Health IH Advantage 6350 Bronze $178 $6,350 $6,350 6 Innovation Health IH AdvantagePlus 5500 PD Bronze $181 $5,500 $6,350 7 CareFirst BlueChoice Inc BlueChoice Plus Bronze $5,500 Bronze $182 $5,500 $6,350 8 Kaiser Permanente KP VA Catastrophic 6350/0/Dental Catastrophic $185 $6,350 $6,350 9 Kaiser Permanente KP VA Bronze 5000/30%/HSA/Dental Bronze $196 $5,000 $6, CareFirst BlueChoice Inc BluePreferred HSA Bronze $3,500 Bronze $197 $3,500 $6, Innovation Health IH Classic 5000 Silver $221 $5,000 $6, CareFirst BlueChoice Inc BlueChoice HSA Silver $1,300 Silver $232 $1,300 $6,350
73 2014 Plan Options: John 73 Applicants (age): John (28) FPL: 296% APTC: $0/month CareFirst CareFirst BlueChoice HSA Bronze $6,000 Annual Cost BlueChoice HSA Silver $1,300 Annual Cost Bronze Silver Monthly Premium $150 $1,800 $232 $2,784 Deductible (medical/drug) $6,000 (comb.) $5,700 $1,300 (comb.) $1,300 Maximum OOP limit $6,000 $6,350 Primary Care Office Visit $0 after ded. $30 after ded. Specialist Office Visit Inpatient hospital Outpatient surgery $0 after ded. $0 after ded. $0 after ded. $40 after ded. 20% after ded. 20% after ded. $200 $340 $360 $7,500 $4,984 Health Emergency: Car accident: hospitalization ($3,000), 5 specialist follow up visits ($180/visit), outpatient surgery ($1800)
74 2015 Marketplace Plan Options (November 2014) 74 Scenario 3: Joe (renewing consumer) Carrier Plan Name Metal Tier Monthly Premium Deductible OOP Max 1 CareFirst BlueChoice Inc BlueChoice HSA Bronze $6,000 Bronze $ $6,000 $6,000 2 Innovation Health VA Innovation Health Bronze HSA Bronze $ $6,300 $6,300 3 CareFirst BlueChoice Inc BlueChoice HSA Bronze $4,000 Bronze $ $4,000 $6,350 4 Kaiser Permanente KP VA Bronze 5000/30%/HSA/Dental Bronze $ $5,000 $6,350 5 Kaiser Permanente KP VA Bronze 4500/50/HSA/Dental Bronze $ $4,500 $6,350 6 Kaiser Permanente KP VA Bronze 4500/50/Dental Bronze $ $4,500 $6,350 7 CareFirst BlueChoice Inc BlueChoice Plus Bronze $5,500 Bronze $ $5,500 $6,350 8 Innovation Health VA Innovation Health Bronze $25 Bronze $ $5,750 $6,600 9 GHMSI BluePreferrred HSA Bronze $3,500 Bronze $ $3,500 $6, Kaiser Permanente KP VA Silver 1750/25%/HSA/Dental Silver $ $1,750 $6, Innovation Health Innovation Silver $10 Copay Silver $ $5,000 $6, Kaiser Permanente KP VA Silver 2500/30/Dental Silver $ $4,000 $6,600
75 2015 Plan Options: John (renewing coverage) 75 Applicants (age): John (29) FPL: APTC: CareFirst* BlueChoice HSA Bronze $6,000* Bronze Monthly Premium $ Deductible (medical/drug) $6,000 (comb.) Maximum OOP limit $6,000 Primary Care Office Visit Specialist Office Visit Inpatient hospital Rx (generic/brand) $0 after ded. $0 after ded. $0 after ded. $0 after ded. Innovation Kaiser Innovation BlueChoice HSA Bronze $4,000 KP VA Silver 1750/ 25%/HSA/Dental Innovation Silver $10 Copay Bronze Silver Silver $ $ $ $4,000 (comb.) $1,750 $4,000/$1,000 $6,350 $5,000 $6,600 $30 after ded. 25% after ded. $10 $40 after ded. 25% after ded. $75 30% after ded. 25% after ded. 30% after ded. 20% after ded. $15/$45 after ded. $5/$45 * current plan
76 Identify Consumers Priorities for Insurance 76 Cheapest monthly payment? Manageable deductible? Low co-pays/co-insurance? Prescription drug covered? Doctor in network? Language spoken by providers? Size and proximity of network? Lowest overall annual cost (premiums + anticipated cost-sharing) Changes based on experience from 2014 plan year
77 CBPP Marketplace Plan Comparison Worksheet 77 available at:
78 Remind Everyone To Go Back To The Marketplace!!! 78
79 Contact Info 79 Sarah Lueck, Dave Chandra, Halley Cloud, For general inquiries: For more information and resources, please visit: This is a project of the Center on Budget and Policy Priorities,
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Harford County Public Schools Blue Choice Open Access Coverage Period: 07/01/2015 06/30/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual Plan Type:
Important Questions Answers Why this Matters: In-network: $0/Individual; $0/Family Out-of-network: $750/Individual; $1,500/Family
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.anthem.com or by calling 1-800-421-1880. Important Questions