Transcript Document

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
• Understanding Plan Benefits & Summary of Benefits and
Coverage (SBC)
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2
Review Basic
Insurance Terminology
3
Simple Terms And Definitions
•
•
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•
4
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.
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Simple Terms And Definitions
•
•
•
5
In Network (Tier 1) –What you 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.
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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:
6
What is the overall
deductible?
$4,500 person/ $9,000 family
Does not apply to preventive services, certain
services with copays and prescription drugs.
You must pay all the costs up to the deductible amount before this plan
begins to pay for covered services you use. Check your policy or plan
document to see when the deductible starts over (usually, but not always,
January 1st). See the chart starting on page 2 for how much you pay for
covered services after you meet the deductible.
Are there other
deductibles for specific
services?
Prescription drugs: $ 500 person in network.
There are no other specific deductibles.
You must pay all of the costs for these services up to the specific deductible
amount before this plan begins to pay for these services.
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Annual Out of Pocket Limit
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•
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•
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%
o Rx copays & deductibles are included in the Maximum Out-of-Pocket
o Maximum Out-of-Pocket Limit applies to In-Network services ONLY
Sample from a SBC document:
Is there an out–of–
pocket limit on
my expenses?
For preferred providers $5,200 person /
$10,400 family
The out-of-pocket limit is the most you could pay during a coverage period
(usually one year) for your share of the cost of covered services. This limit
helps you plan for health care expenses.
What is not included in
the out–of–pocket limit?
Premiums, balance billed charges and health
care this plan doesn't cover.
Even though you pay these expenses, they don't count toward the out-ofpocket limit.
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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.
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Allowed Amount & Balance Billing
Allowed Amount
Maximum amount on which payment is based for covered health
care services. This may be called “eligible expense,” “payment
allowance” or “negotiated rate.”
Balance Billing
When 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.
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Copay & Coinsurance / Allowed Amount & Balance Billing
Sample from a SBC document:
Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.
Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if
the plan’s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if
you haven’t met your deductible.
The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the
allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and
the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)
This plan may encourage you to use preferred providers by charging you lower deductibles, copayments and coinsurance amounts.
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Key Things to Consider When
Distinguishing
Between Carriers & Benefit Coverage
Shopping Readiness
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Key Questions That Influence
An Individual’s Shopping Decisions
• What is most important to the person who is looking for a plan?
o Are they currently insured? Happy with your current carrier?
o Low premium? Low cost-sharing charges?
o Providers or Hospital?
• What does their budget allow for health coverage?
o 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?
o Do you have a medical conditions?
o Are you or any family member attached to seeing a particular physician?
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Choosing Your Current Carrier
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•
•
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Is your current carrier offering plans on the Exchange?
o 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.
o Formulary is to specify particular medications that are
approved to be prescribed under a particular insurance
policy.
o A carriers formulary and drug coverage level can change
based on plan type
o 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.
o A carriers networks can change based on plan type.
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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
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Advanced Premium Tax Credit (APTC) &
Cost Sharing Reduction (CSR) Sample
Actual C4HCO Silver Plan (Based on a 28 year old male, Denver zip code)
CSR Plan
Standard Silver 201 - 250%
No CSR
FPL
CSR Plan
up to 150%
FPL
Annual income
$35,000
$27,000
$20,000
$17,000
Actuarial Value
70%
73%
87%
94%
$212.96
$169.30
$85.12
$54.96
APTC Monthly Amount
$0.00
$43.66
$127.84
$158.00
Medical Deductible Individual
$4,600
$3,250
$900
$500
Medical Deductible Family
$9,200
$6,500
$1,800
$1,000
Drug Deductible Individual
$1,500
$1,000
$500
$250
Drug Deductible Family
$3,000
$2,000
$1,000
$250
Max. Out-of-Pocket Individual
$6,300
$4,750
$1,450
$750
Max. Out-of-Pocket Family
$12,600
$9,500
$2,900
$1,500
Monthly Premium
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CSR Plan
150 - 200%
FPL
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Do You Have a Medical Conditions?
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Preexisting conditions can no longer be used to deny coverage or be used to
increase their premium.
o Do you have a specific physician or facility treating you for this condition?
o Do you take certain medications to treat the condition?
• The carriers plan benefit page has a link to their formulary
o How often do you require testing services? Lab / Radiology ?
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Are You or a Family Member
Attached to a Physician?
• OB/GYN?
o Primary care physicians
o Primary care copay
• Children's Pediatrician?
o Primary care physicians
o Primary care copay
• Specialist?
o Specialist visit copay
o A person could have had a heart condition 10 years ago, but continues to see his
Cardiologist once a year for a check up
o Some plans may require a Primary care referral to access a Specialist
• Hospitals can also play an important role
o In their neighborhood
o Easy access
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What Three Factors influence's my premiums?
Your Age, Tobacco Use, Location
Your age
o 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
o Most plans (not all) increase their rates for tobacco user
o 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
o Colorado has 11 rating areas based on varies counties, determined by the DOI
o If your coverage is through your employer, the rate is based on the employer’s
zip code & county
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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
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SM Rate Age
Rate
Age 21 to 65 has a 67% increase
Age
Rate
SM Rate Age
Rate
SM Rate Age
Rate
SM Rate
20
$129.52
$129.52
32
$241.30
$277.50
44
$284.95
$327.70
56
$475.88
$547.26
21
$203.98
$234.57
33
$244.36
$281.02
45
$294.54
$338.72
57
$497.09
$571.65
22
$203.98
$234.57
34
$247.63
$284.77
46
$305.96
$351.86
58
$519.73
$597.69
23
$203.98
$234.57
35
$249.26
$286.65
47
$318.81
$366.64
59
$530.95
$610.59
24
$203.98
$234.57
36
$250.89
$288.52
48
$333.50
$383.53
60
$553.59
$636.63
25
$204.79
$235.51
37
$252.52
$290.40
49
$347.98
$400.18
61
$573.17
$659.15
26
$208.87
$240.20
38
$254.15
$292.28
50
$364.30
$418.95
62
$586.02
$673.93
27
$213.77
$245.83
39
$257.42
$296.03
51
$380.41
$437.48
63
$602.14
$692.46
28
$221.72
$254.98
40
$260.68
$299.78
52
$398.16
$457.88
64
$611.92
$703.71
29
$228.25
$262.49
41
$265.58
$305.41
53
$416.11
$478.53 65 + $611.92
$703.71
30
$231.51
$266.24
42
$270.27
$310.81
54
$435.49
$500.81
31
$236.41
$271.87
43
$276.80
$318.31
55
$454.87
$523.10
Anyone over 65 would
receive the same rate
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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
Rating Area 1
Rating Area 2
Rating Area 3
Rating Area 4
Rating Area 5
Rating Area 6
Rating Area 7
Rating Area 8
Rating Area 9
Rating Area 10
Rating Area 11
Boulder
Boulder County
Colo Springs
El Paso
Teller
Denver
Adams
Arapahoe
Broomfield
Clear Creek
Denver
Douglas
Elbert
Gilpin
Jefferson
Park
Fort Collins
Larimer
Grand Junction
Mesa
Greeley
Weld
Pueblo
Pueblo
SouthEast
Baca
Bent
Cheyenne
Crowley
Custer
Frmont
Huerfano
Kiowa
Kit Carson
Las Animas
Lincoln
Mineral
Otero
Prowers
Alamosa
Chaffee
Conejos
Costilla
Rio Grande
Saguache
NorthEast
Logan
Morgan
Phillips
Sedwick
Washington
Yuma
West
Archuleta
Delta
Dolores
Grand
Gunnison
Hinsdale
Jackson
La Plata
Lake
Moffat
Montezuma
Montrose
Ouray
Rio Blanco
Routt
San Juan
San Miguel
Resort
Eagle
Garfield
Pitkin
Summit
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Understanding Plan Benefits & Summary
of Benefits and Coverage (SBC)
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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:
•
o
o
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 30 OR get a "hardship exemption"
from the Federal Government.
o
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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).
22
Cost-Sharing and Metal Tiers
ACA Precious Metal Tiers
In general, lower
member cost-sharing
and higher premiums
In general, higher
member cost-sharing
and lower premiums
23
Plan Tier
Actuarial
Value
Platinum
90%
Gold
80%
Silver
70%
Bronze
60%
Actuarial value
percentages represent
how much of a typical
population’s medical
spending a health
insurance plan would
cover.
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Benefit Comparison By Metal Tier
Benefits
Ded Individual
Ded Family
Ded Rx Ind
Ded Rx Family
OOPMax Ind
OOPMax Family
Primary Care
Specialist visit
Prevention visit
Diagnostic Test
Imaging
Generic Drugs
Preferred Drugs
Non-Preferred
Specialty Drugs
Facility Outpatient
Facility Inpatient
Emergency visit
Emergency Trans
Urgent Care
Premium
Catastrophic Plan
$6500 per person
N/A
N/A
N/A
$6,350
$12,700
Copay Gold Plan
$1500 per person
N/A
$150 per person T2-4
N/A
$3,200
$6,400
Copay Platinum Plan
$500 per person
N/A
N/A
N/A
$1,500
$3,000
3 OV per person
$50 Copay / 20% Coin
$35 Copay / 20% Coin
$20 Copay / 20% Coin
$10 Copay / 10% Coin
No Charge after Ded
No Charge $0 Copay
No Charge after Ded
No Charge after Ded
No Charge after Ded
No Charge after Ded
No Charge after Ded
No Charge after Ded
No Charge after Ded
No Charge after Ded
No Charge after Ded
No Charge after Ded
No Charge after Ded
$288.49
$100 Copay / 20% Coin
No Charge $0 Copay
20% Coin
20% Coin
20% Coin
20% Coin
20% Coin
20% Coin
20% Coin
20% Coin
20% Coin
20% Coin
20% Coin
$322.22
$60 Copay / 20% Coin
No Charge $0 Copay
20% Coin
20% Coin
$15 Copay
$40 Copay/After Ded
$80 Copay/After Ded
25% of nego. Rate
20% Coin
20% Coin
20% Coin
20% Coin
20% Coin
$343.75
$40 Copay / 20% Coin
No Charge $0 Copay
20% Coin
20% Coin
$15 Copay
$35 Copay/After Ded
$70 Copay/After Ded
$250 Copay/After Ded
20% Coin
20% Coin
$300 Copay
$300 Copay
$75 Copay
$395.19
$20 Copay / 10% Coin
No Charge $0 Copay
10% Coin
10% Coin
$10 Copay
$35 Copay
$60 Copay
$250 Copay
10% Coin
10% Coin
$250 Copay
10% Coin
$75 Copay
$470.62
10%
16%
27%
39%
% increase Catastrophic Plan
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Actual C4HCO Carrier Individual Plans
Copay Bronze Plan
Copay Silver Plan
$5500 per person
$5000 per person
N/A
N/A
N/A
$500 per person T2-4
N/A
N/A
$6,350
$6,350
$12,700
$12,700
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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)
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Benefit Comparison By HMO & PPO Sample
Benefits
Silver HMO
In Network
Ded Individual
$1,500
Ded Family
$3,000
Rx Ded Individual
$250 per person
Rx Ded Family
N/A
OOPMax Ind
$6,350
OOPMax Family
$12,700
Primary Care
$30 Copay
Specialist visit
$50 Copay
Prevention visit
100% covered
Diagnostic Test
30% Coinsurance
Imaging
$250 Copay
Generic Drugs
$15 Copay
Preferred Drugs
$45 Copay
Non-Preferred
30% Coinsurance
Specialty Drugs
30% Coinsurance
Facility Outpatient
30% Coinsurance
Facility Inpatient
30% Coinsurance
Emergency visit
$350 Copay
Emergency Trans
30% Coinsurance
Urgent Care
$75 Copay
Premium
$221.72
% increase Lowest Plan
26
Silver PPO
In Network
$5,000
$10,000
N/A
N/A
$5,000
$10,000
$30 Copay
$60 Copay
100% covered
100% covered After Ded
100% covered After Ded
$4 Copay
$15 Copay
$45 Copay
50% Coinsurance
100% covered After Ded
100% covered After Ded
100% covered After Ded
100% covered After Ded
$75 Copay
$277.86
20%
Out of Network
$12,500
$25,000
N/A
N/A
$25,000
$50,000
50% Coinsurance
50% Coinsurance
100% covered
50% Coinsurance
50% Coinsurance
Not Covered
Not Covered
Not Covered
Not Covered
50% Coinsurance
50% Coinsurance
50% Coinsurance
50% Coinsurance
50% Coinsurance
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What Applies to Maximum Out-of-Pocket
HMO & EPO Plans
Copayments
Deductibles
Rx
Deductibles
Coinsurance
Rx
Coinsurance
Rx
Copayments
Maximum
Out-of-Pocket
$6,350 / $12,700
Prevention
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What Applies to Maximum Out-of-Pocket
HMO & EPO Plans
Deductibles
Rx
Copayments
Copayments
Coinsurance
Out-of-Pocket
Limit
Maximum
Out-of-Pocket
$6,350 / $12,700
Prevention
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What Applies to Maximum Out-of-Pocket
PPO Plans
In Network Services
Copayments
Deductibles
Out of Network Services
Rx
Copayments
Deductibles
Coinsurance
Coinsurance
Maximum
Out-of-Pocket
$6,350 / $12,700
Out-of-Pocket
Max.
Prevention
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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.
Cost of
John's
services
expenses
John's Medical Services
$100
$0
Prevention visit
$80
$30
PCP visit
$100
$100
PCP orders meds Preferred
$150
$50
Specialist visit
$100
$100
Specialist orders Lab
$1,000
$400
Emergency visit
$1,000
$1,000
Ambulance ride to ER
$1,500
$300
ER test MRI
$150
$150
ER meds Specialty Drug
$145
$45
ER med Preferred
$115
$15
ER med Generic
$5,000
$2,480
Inpatient Hospital
(John paid $1400 & $1080 (30% of $3600)
$3,000
$900
X-rays & Lab
$2,500
$750
Physician surgery
$500
$30
Inpt Hosp meds 2 Generics
$1,000
$0
Rehab
30
Total
$16,440
$6,350
Applies to Applies to
Med Ded
Rx Ded
$0
$0
$0
$0
$0
$100
$0
$0
$100
$0
$0
$0
$1,000
$0
$0
$0
$0
$150
$0
Ded met
$0
$0
$1,400
$0
Ded met
$0
$0
$0
$0
$0
$0
$0
$0
$2,500
$250
Applies to
OOP max
$0
$30
$100
$50
$100
$400
$1,000
$300
$150
$45
$15
$2,480
Carrier
expenses
$100
$50
$0
$100
$0
$600
$0
$1,200
$0
$100
$100
$2,520
$900
$750
$30
$0
$6,350
$2,100
$1,750
$470
$1,000
$10,090
This plan has a single Rx
Deductible even for
family. That means each
family member has a
$250 Rx deductible
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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
Bills Medical Services
Prevention visit
PCP visit
PCP orders meds Preferred
Specialist visit
Specialist orders Lab
Emergency visit
Ambulance ride to ER
ER test MRI
ER meds Specialty Drug
ER med Preferred
ER med Generic
Total
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Cost of
sevices
$100
$80
$100
$200
$100
$2,000
$1,000
$1,500
$350
$200
$50
$5,680
Bill's
Applies to Applies to Carrier
Expenses Med Ded OOP max expenses
$0
$0
$0
$100
$35
$35
$35
$50
$100
$100
$100
$0
$200
$200
$200
$0
$100
$100
$100
$0
$2,000
$2,000
$2,000
$0
$1,000
$1,000
$1,000
$0
$1,500
$1,500
$1,500
$0
$350
$350
$350
$0
$200
$200
$200
$0
$50
$50
$50
$0
$5,535
$5,535
$5,535
$150
All plans cover Prevention
At no cost
All Catastrophic plans
cover 3 PCP visits per
year not subject to the
Deductible
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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
Company Profile: Standard document
Covers – Company at a glance, Medical
Loss Ratio, Unique Offerings & Programs,
Awards & Recognition,& In the Community.
English & Spanish
Carrier Marketing materials:
Not Standard, Varies by carrier
English & Spanish
32
Summary of Benefits and Coverage, is a summary
of benefits (not a binding contract), standard benefit
Layout (9 pages) 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
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Shopping Scenario's
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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)
o Ded $5000 / OOP $6350, OV 30% (After Ded), Rx 30% (After Ded)
•
Actual C4HCO Bronze HMO (227.65)
o Ded $6300 / OOP $6300, OV No Charge (After Ded), Rx No Charge (After Ded)
•
Actual C4HCO Gold HMO ($297.11)
o Ded $1600 / OOP $500, OV $15 / $25 copays, Rx $10 / $35 / $60 copays
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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)
o 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)
o Ded$5000/OOP$6350,OV30%(After Ded)Rx 30%(After Ded)Facility30%(After Ded)
•
Actual C4HCO Silver HMO ($227.65) + Medical expenses ($2250) = ($4982)
o Ded $0 / OOP $2250, OV $15/$25 copay, Rx $15/$45/20% Facility 20% (After Ded)
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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)
o Ded $0 / OOP $0, OV 0%, Rx 0%
•
Actual C4HCO Silver HMO ($144.07)
o Ded $0 / OOP $0, OV No Charge (After Ded), Rx No Charge (After Ded)
•
Actual C4HCO Gold HMO ($182.55)
o Ded $0 / OOP $0, OV $0 / $0 copays, Rx $0 / $0 / $0 copays
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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
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