Many of the health insurance regulations in the ACA have made it easier to compare apples to apples in the individual health insurance market. There are no more “junk” plans with low benefit maximums or major holes in the coverage. All policies cover maternity (although that has been the case in Colorado since 2011). Preventive care is covered before the deductible with no copays or coinsurance. All policies must cover the essential health benefits with no annual or lifetime maximums (there can still be limits on the number of visits for some treatments). And all policies must have out-of-pocket maximums of no more than $6350 ($12,700 family) in 2014.
Other than Catastrophic plans, which are available for people under 30 and those who have a hardship exemption from the exchange, which includes people who had a 2013 policy that was terminated in December, all policies available in Connect for Health Colorado (and off-exchange too) fall into one of four categories: bronze, silver, gold or platinum (virtually all of them are bronze, silver or gold though). Also, Catastrophic plans aren’t significantly less expensive in Colorado. The designation is based on the actuarial value of each policy. Bronze plans cover roughly 60% of costs; silver, 70%; gold, 80%; and platinum, 90%. After the maximum out-of-pocket is met, all policies cover 100% of covered costs (with some rare exceptions, such as policies that put an annual limit on the number of covered visits for services like home healthcare and skilled nursing).
But comparing apples to apples still takes quite a bit of reading. Within each metal level, there’s a wide variety of different plans available from the many different carriers offering policies in the exchange (Anthem Blue Cross Blue Shield, Cigna, Colorado HealthOP, Elevate by Denver Health, Humana, Kaiser Permanente, Rocky Mountain Health Plans, United Health). Networks vary considerably, but so do the plan designs themselves. Here’s a summary of the main ways that policies differ from one another (Any deductibles and out-of-pocket maximums mentioned are for an individual; they are generally double that amount for a family. If you’re unsure of any terminology, our glossary may be helpful – or feel free to contact us with questions):
- Deductibles vary from $0 to $6350. There are several plans with deductibles under $1000, and several with deductibles over $6000. Low deductible plans tend to have the highest premiums.
- Maximum out-of-pocket expenses (not counting premiums, out-of-network balance billing and benefits that are not covered, such as infertility treatment, cosmetic surgery and bariatric surgery) cannot exceed $6350 for an individual. Many of the policies available in the exchange have a maximum OOP in the $6000 – $6350 range. But there are plans with much lower maximum OOP, in the $3500 range. There’s even a platinum plan from Humana that caps the OOP at $1,500. The premiums are higher for the plans with lower OOP maximums, but all policies are guaranteed issue now, regardless of health history. If you know that you’re going to have significant medical expenses this year, it’s worth crunching the numbers to see if the additional premiums would be offset by the lower OOP maximum.
- Office visits are covered with copays on most plans before the deductible, although some policies (especially if they are HSA qualified – see next bullet point) require you to meet your deductible first and then cover office visits at the coinsurance rate. For plans that have copays, they’re mostly in the range of $25 – $50 for primary care and $50 – $75 for specialists. Some plans cover the first two visits with a copay and switch to deductible and coinsurance for additional visits. Occupational, speech and physical therapy are sometimes covered with copays as well, although these services are also frequently counted towards the deductible and covered at the coinsurance level once the deductible is met.
- HSA qualified policies must follow the rules regarding HSA plan design, which predate the ACA and include a requirement that treatment other than preventive care is not covered until the insured has met the minimum deductible requirement, which is $1250 for 2014. The HSA-qualified plans in Connect for Health Colorado generally have higher deductibles and only cover preventive care and mandated women’s health benefits (including contraceptives) before the deductible.
- Maternity care is covered on all plans, but the way it is covered differs from one plan to another. Some count prenatal visits as a regular office visit, charging just a copay. Others count prenatal care together with delivery and apply the policy’s deductible and coinsurance (and some policies have a separate hospital copay that must also be met, if you have not yet met your maximum out-of-pocket for the year).
- Chiropractic care and acupuncture are not classified as essential health benefits and many policies do not cover them. But some do (for example, there are Humana plans that cover up to 10 chiropractic visits per year at the coinsurance rate, after the deductible is met).
- Prescription coverage varies considerably. Some policies have separate prescription deductibles that apply to all drugs or only to brand name and specialty drugs. Some policies cover prescriptions with coinsurance after the deductible (and count them towards the deductible if you haven’t yet met it for the year). Some policies just have straight copays for prescriptions, while others have copays for lower tier medications and coinsurance for higher tier drugs (copays are flat dollar amounts, while coinsurance is a percentage of the total cost).
- Urgent care and emergency room visits can be subject to the deductible and coinsurance, or they can have copays, or both. If there’s a copay, it’s usually around $75 for urgent care and in the range of $200 – $400 for the ER. In some cases, that copay is all you pay as long as your care is confined to the ER or urgent care clinic (if you’re admitted to the hospital, your coverage switches to the way that your benefits cover hospitalization instead). In other cases, you pay the copay in addition to your deductible and coinsurance, assuming it doesn’t put you over your maximum out-of-pocket for the year. And other policies have a copay that is waived if you’re admitted to the hospital from the ER (in that case, the deductible and coinsurance apply, as well as a hospital copay if your plan has one).
- Hospitalization is covered on all plans, and in almost all cases you’ll be responsible for the deductible and coinsurance. Some policies also have a facility copay ($500 or $1000 are the most common amounts) that is charged if you’re hospitalized. Again, all of this counts towards the maximum out-of-pocket for the year.
- Mental health care and substance abuse treatment are covered on all plans. Some policies cover outpatient mental health and addiction treatment with copays (similar to a regular office visit), while others apply the policy’s deductible and coinsurance. Some policies cover all inpatient therapy while others limit inpatient substance abuse therapy to detox only.
- Pediatric vision is covered on all policies, but can be limited to eye exams only (no glasses). But most plans at least partially cover the cost of glasses. Vision coverage for adults is not required and generally not covered.
- Pediatric dental is covered on some plans, but can also be purchased as a stand-alone plan in Connect for Health Colorado (pediatric dental is different from the other essential health benefits – here’s more information). Adult dental is not a mandated benefit.
We work with all of the carriers in Connect for Health Colorado, and all of the major off-exchange carriers too. For example, Assurant/Fortis is ONLY available off exchange. If you’re concerned about the limited HMO and EPO networks inside the exchange, Assurant uses the nationwide Aetna Signature Administrators PPO network. If you’re unsure of how to find the best plan to fit your needs and budget, please let us know what questions you have, via email or phone. As always, there is no charge for our service.