Series for Covered CA: Part 2

Different Health Plans

PRESIDENT-elect Trump vowed to repeal at least parts of Affordable Care Act (ACA). Certain parts of that he will maintain, as he wants all Americans to have insurance and to maintain health coverage for those who have pre-existing health condition. Surely change will come, but for now, Covered CA assures Californians that 1) your coverage will remain intact for 2017 and foreseeable future, 2) your financial assistance (subsidies, APTC/CSR, small business tax credits) are protected under the law, and 3) the rates for 2017 will not change.

With that assurance, we can focus on selecting health plans. There are four (4) metallic plans available: Bronze, Silver, Gold and Platinum. If you are less than 30 yrs. old, you can also have minimum coverage. Broadly, the differences are in how much the health insurance pays claims, from 60 percent to 90 percent of the costs. Minimum coverage plans cover least while Platinum plans cover most. Even if the plans do not cover 100 percent, one noteworthy fact is that health insurance benefit is unlimited which is especially helpful for people who are in catastrophic circumstances. For 2017, another invaluable fact is that you will not have to pay more than $7,100 if you have a minimum coverage plan and $4,000 if you have a Platinum plan — the maximum out-of-pocket cost.

Bronze plans have fixed copays only on primary care doctor’s visits, specialist visits, urgent care and lab. They are $75, $105, $75 and $40 respectively. For the rest of the services you are on your own until you reach the $6,300 deductible before the bronze plan will help you. Silver and above have better protection. Also, when you select a Silver plan, you may be offered an Enhanced Silver rather than a Standard Silver. What does it mean? Lower copays. For example, primary care visit copay for Silver 70 is $35, Silver 73 is $30, Silver 87 is $10 and Silver 94 and $5.

Health plans differ by HMO, PPO, EPO and HSP.

A Health Maintenance Organization (HMO) plan is a plan that requires you to have a Primary Care Physician (PCP). The PCP will be the one who refers you to the specialists. These specialists are typically within the same medical group as the PCP. If the specialists are not in that medical group, then most likely you won’t be able to see them. As for the services and the procedures they have to be arranged first by the doctors and approved by the medical group. This managed care plan essentially reduces the size of the network of providers to only the ones that are contracted with the medical group. This type of plan also demands your patience as time and effort is needed in seeking referral and approval.

A Preferred Provider Organization (PPO) plan on the other hand has much wider network and gives you direct access to the specialists. So if you need to see say your ophthalmologist, you can just dial his number and set an appointment. You can go to both in-network and out-of-network providers. But you want to use in-network providers in most cases. Why? Again, to keep your costs down. Although your PPO plan may pay to out-of-network providers, the amount will only be very little compared to your share.

An Exclusive Provider Organization (EPO) is similar to a PPO in that you don’t need to designate a PCP. You don’t need referrals to see specialists. The main difference between EPO and PPO is that you cannot use out-of-network providers at all. You should stay within the network exclusive to your plan.

A Health care Savings Plan (HSP) is a hybrid between HMO and EPO. It’s like HMO because most HSPs will require you to designate a PCP. It’s like an EPO because you can see specialists without referrals but you can’t go outside the network.

A variation of these types is a Health Savings Account (HSP) health insurance plan. If you have these, you can tax deduct the amount contributed into an HSP account and normally the amount here is used to pay high deductibles and other medical expenses.

Renewal for Jan 1, 2017 effective date is still ongoing. New applicants can enroll between Nov 1, 2016 and Jan 31, 2017. If you need help renewing or enrolling, please call 855-955-1800 or visit an official Covered CA storefront near you.

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If you have more questions regarding the enrollment periods or other insurance questions, feel free to ask the author for answers. A good telephone number to reach him is 855-955-1800. You can also check out


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