Monday, June 02, 2014

How will medical insurance plans change for the 2015 plan year?


Some details on the 2015 plans were made available in the last couple weeks which I want to share.

First some background. Federal health reform required a change in the design of medical insurance plans. IOW the deductible, co-pays, and cost sharing amounts are used in a different way. These changes began January 1, 2014.

Medical insurance plans, whether purchased in the Individual or Small Group market, have to meet certain requirements. The basics of these changes are:

● Plans must cover 10 Essential Health Benefits (EHB). Two are new to Conn. Pediatric dental coverage (for age 19 and under) and what is called habilitative services. Rehabilitative services help an individual recuperate for example following hip surgery. This coverage stops when the person is no longer improving. Habilitative coverage helps a person who is no longer improving but their condition would decline if certain services were to stop. It’s only available for certain conditions.

● Each health insurance company must use a complex calculation to determine how much of a person’s medical treatment expenses the company pays and how much an individual will pay. This calculation results in what is called the plans Actuarial Value (AV).

There are four AV levels. Platinum, which has to cover 90% of the required EHBs. Gold covers 80%, Silver is 70%, and Bronze is 60%.

A person might think when looking, for example, at a Silver plan – oh my if I have $100,000 in medical expenses I will have to pay $30,000. The answer is NO. A person’s expenses, if a major treatment situation were to occur, are limited each plan year by the maximum out of pocket (MOP) provision. This limit is adjusted each year.


Second let’s look at the highlights of a person’s coverage during 2014, who is enrolled in the Standard Silver Individual plan through Access Health CT:
● No cost for a variety of preventive exams and tests.
● A $30 co-pay for a primary care doctor visit and $45 to see a specialist
● Other medical treatment is covered after a $3,000 deductible.
● A $400 deductible on prescriptions and then a $10 co-pay for Generics, $25 for preferred brands, $40 for non-preferred brands, and 40% cost sharing for specialty medications.
● A $75 co-pay for Urgent care and a $150 co-pay for an emergency room visit.
● A $500 co-pay for outpatient surgery
● A $500 per day co-pay for hospitalization up to $2,000 is applied after the medical deductible has been met.
● A MOP of $6,350 for Single coverage. The MOP is doubled when a person enrolls one or more dependents on their plan.

Third let’s look at the highlights of Access Health CT plans for the Standard Silver Individual plan in 2015:
● No cost for a variety of preventive exams and tests.
● A $40 co-pay for up to three primary care doctor visit and $50 to see a specialist.
● Other medical treatment is covered after a $2,600 deductible.
● Generic medications will have $5 co-pays, Preferred brands at $30, and non-preferred brands at $55 with no deductible. Specialty medications will have a $60 co-pay after a $25 deductible.
● A $75 co-pay for Urgent care, after the deductible, and a $150 co-pay for an emergency room visit.
● A $500 co-pay for outpatient surgery
● A $500 per day co-pay up to $2,000, for hospitalization after the medical deductible has been met
● A MOP of $6,600 for Single coverage. The MOP is doubled when a person enrolls one or more dependents on their plan.

There may be some variation in this coverage between the health insurance companies offering these plans effective January 1, 2015.

What companies will be available for 2015? It is anticipated additional companies will apply to offer plans through Access Health CT in 2015.

How much higher will the premiums be in 2015? A BIG unknown. The Access Health CT consultants indicated the 2015 plan changes should not result in much of an increase. Of course the big unknown is what impact the every increasing cost of medical treatment will have.

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