- Email: [email protected]
Health Care Exchange Insurance Plan Levels
Health Care Exchange Insurance Plan Levels QUESTION: what are the plan levels and what do
they offer to patients? ANSWER: According to the Kaiser foundation, 62% of nonelderly adults receive insurance through their employers. The Affordable Care Act provides a pathway for those not eligible for Medicare or Medicaid to get insurance through health care exchanges. Within the exchanges, there are 5 levels of coverage: bronze, silver, gold, platinum, and catastrophic. A brief overview of the plans and what they can provide to patients follows. First, bronze-, silver-, gold-, and platinum-level plans must provide at least the following essential health benefits but could offer more: Ambulatory patient services Emergency services Hospitalization Maternity and newborn care Mental health and substance use disorder services Prescription drugs Rehabilitative and habilitative services and devices Laboratory services Preventive and wellness services and chronic disease management Pediatric services, including oral and vision care The plans are differentiated by their actuarial value (AV). This is the total average cost of the plan. So, if a plan has an AV of 70%, it is expected the plan will pay 70% of the cost while the patient will pay 30% of the cost over a year. Each plan now has an AV designation as follows: bronze, 60%; silver, 70%; gold, 80%; and platinum, 90%. Let’s take just a minute to go over the catastrophic plan. These plans have an AV less than 60%. They generally have a deductible of thousands of dollars and are designed to provide coverage for serious accidents or illness. The premiums are less than the other plans and are for people under the age of 30 or someone with www.npjournal.org
SHAPING POLICY, IMPROVING PRACTICE Angela Golden, DNP
a hardship exemption. The following are examples of hardship exemptions: recent domestic violence; eviction in the past 6 months; fire, flood, or other disaster; and bankruptcy in the past 6 months. The good thing is that these plans must still provide a prevention package, and it includes 3 primary care visits a year at no cost and numerous preventive visits such as screenings for sexually transmitted diseases and human immunodeficiency virus as well as immunizations. The lowest premium cost for a catastrophic plan I could find was in Missouri, and it was $107 per month with the highest at $180 per month in California. The bronze plans have the lowest monthly premiums, but patients have a higher share of the costs as they occur. There is a cap in 2015 for out-of-pocket costs; in the bronze plan, it will be $6,600 for individual plans and $13,200 for family plans. Premiums will increase based on age as well, but an average monthly premium for an individual 40 years old is $296 per month.1 Twenty percent of individuals chose a bronze plan in 2014. Silver plans are the most commonly selected; 65% of people who purchased health insurance in the health care exchange in 2014 paid for this plan level. The cap in 2015 for out-of-pocket costs in the silver plan will be $5,775 for individual plans and $11,555 for family plans. The average monthly premium for a 40-year-old person is $319 per month.1 Gold plans have the second lowest outof-pocket costs and generally offer enhanced The Journal for Nurse Practitioners - JNP
379
benefits as well. One big difference in the gold plan is that the premiums are not included in the out-of-pocket costs of 20%. The cap will not include the amount paid for the premiums; this will only be the amounts actually paid for provider visits, labs, radiology, hospital care, and so on. Bronze and silver plans do include the premiums, so this adds some confusion to the comparison of plans when patients are trying to select the best plan. A 40-year-old person could expect a monthly premium of $378 per month.1 The annual cap for an individual is $4,298, and for a family it is $8,986. In 2014, about 9% of individuals selected a marketplace plan at the gold level. The top level of the health insurance plans is the platinum plan, and only about 5% of people selected this plan level. It has the lowest outof-pocket expense for patients estimated at 10%. These plans do have the highest premiums; a 40-year-old person will have a monthly premium of $388.1 The annual cap for an individual is $1,971, and for a family it is $3,942. Similar to employer-based insurance, the plans have different ways of sharing costs. It is important to read through the entire policy to determine cost sharing for things such as medications, visits to specialists, and deductibles for individuals and family members, which could impact the overall expense of the plan. This system is a mirror system of our employerbased system.
380
The Journal for Nurse Practitioners - JNP
One of the major goals of the Patient Protection and Affordable Care Act was to create a system that provided insurance for as many Americans as possible. The first year of enrollment reached over 8 million Americans. Enrollment for 2015 is underway, and in April 2015 it will be completed. How this is operationalized is something to be watched as we move forward with the current law. Please be sure to send me your questions at npfromhome@ gmail.com. RESOURCES 2014 Poverty Guidelines: http://aspe.hhs.gov/ poverty/14poverty.cfm Marketplace insurance categories: https://www. healthcare.gov/choose-a-plan/plans-categories/ 2014 Employer Health Benefits Survey, summary of findings: http://kff.org/report -section/ehbs-2014-summary-of-findings/ Reference 1. HealthPocket. http://www.healthpocket.com/individual-health -insurance. Accessed.
Angela Golden, DNP, is the immediate past president of the American Association of Nurse Practitioners and is a family nurse practitioner in her own practice in Munds Park, AZ. She can be reached at [email protected].
1555-4155/15/$ see front matter © 2015 Elsevier, Inc. All rights reserved. http://dx.doi.org/10.1016/j.nurpra.2014.11.027
Volume 11, Issue 3, March 2015
they offer to patients? ANSWER: According to the Kaiser foundation, 62% of nonelderly adults receive insurance through their employers. The Affordable Care Act provides a pathway for those not eligible for Medicare or Medicaid to get insurance through health care exchanges. Within the exchanges, there are 5 levels of coverage: bronze, silver, gold, platinum, and catastrophic. A brief overview of the plans and what they can provide to patients follows. First, bronze-, silver-, gold-, and platinum-level plans must provide at least the following essential health benefits but could offer more: Ambulatory patient services Emergency services Hospitalization Maternity and newborn care Mental health and substance use disorder services Prescription drugs Rehabilitative and habilitative services and devices Laboratory services Preventive and wellness services and chronic disease management Pediatric services, including oral and vision care The plans are differentiated by their actuarial value (AV). This is the total average cost of the plan. So, if a plan has an AV of 70%, it is expected the plan will pay 70% of the cost while the patient will pay 30% of the cost over a year. Each plan now has an AV designation as follows: bronze, 60%; silver, 70%; gold, 80%; and platinum, 90%. Let’s take just a minute to go over the catastrophic plan. These plans have an AV less than 60%. They generally have a deductible of thousands of dollars and are designed to provide coverage for serious accidents or illness. The premiums are less than the other plans and are for people under the age of 30 or someone with www.npjournal.org
SHAPING POLICY, IMPROVING PRACTICE Angela Golden, DNP
a hardship exemption. The following are examples of hardship exemptions: recent domestic violence; eviction in the past 6 months; fire, flood, or other disaster; and bankruptcy in the past 6 months. The good thing is that these plans must still provide a prevention package, and it includes 3 primary care visits a year at no cost and numerous preventive visits such as screenings for sexually transmitted diseases and human immunodeficiency virus as well as immunizations. The lowest premium cost for a catastrophic plan I could find was in Missouri, and it was $107 per month with the highest at $180 per month in California. The bronze plans have the lowest monthly premiums, but patients have a higher share of the costs as they occur. There is a cap in 2015 for out-of-pocket costs; in the bronze plan, it will be $6,600 for individual plans and $13,200 for family plans. Premiums will increase based on age as well, but an average monthly premium for an individual 40 years old is $296 per month.1 Twenty percent of individuals chose a bronze plan in 2014. Silver plans are the most commonly selected; 65% of people who purchased health insurance in the health care exchange in 2014 paid for this plan level. The cap in 2015 for out-of-pocket costs in the silver plan will be $5,775 for individual plans and $11,555 for family plans. The average monthly premium for a 40-year-old person is $319 per month.1 Gold plans have the second lowest outof-pocket costs and generally offer enhanced The Journal for Nurse Practitioners - JNP
379
benefits as well. One big difference in the gold plan is that the premiums are not included in the out-of-pocket costs of 20%. The cap will not include the amount paid for the premiums; this will only be the amounts actually paid for provider visits, labs, radiology, hospital care, and so on. Bronze and silver plans do include the premiums, so this adds some confusion to the comparison of plans when patients are trying to select the best plan. A 40-year-old person could expect a monthly premium of $378 per month.1 The annual cap for an individual is $4,298, and for a family it is $8,986. In 2014, about 9% of individuals selected a marketplace plan at the gold level. The top level of the health insurance plans is the platinum plan, and only about 5% of people selected this plan level. It has the lowest outof-pocket expense for patients estimated at 10%. These plans do have the highest premiums; a 40-year-old person will have a monthly premium of $388.1 The annual cap for an individual is $1,971, and for a family it is $3,942. Similar to employer-based insurance, the plans have different ways of sharing costs. It is important to read through the entire policy to determine cost sharing for things such as medications, visits to specialists, and deductibles for individuals and family members, which could impact the overall expense of the plan. This system is a mirror system of our employerbased system.
380
The Journal for Nurse Practitioners - JNP
One of the major goals of the Patient Protection and Affordable Care Act was to create a system that provided insurance for as many Americans as possible. The first year of enrollment reached over 8 million Americans. Enrollment for 2015 is underway, and in April 2015 it will be completed. How this is operationalized is something to be watched as we move forward with the current law. Please be sure to send me your questions at npfromhome@ gmail.com. RESOURCES 2014 Poverty Guidelines: http://aspe.hhs.gov/ poverty/14poverty.cfm Marketplace insurance categories: https://www. healthcare.gov/choose-a-plan/plans-categories/ 2014 Employer Health Benefits Survey, summary of findings: http://kff.org/report -section/ehbs-2014-summary-of-findings/ Reference 1. HealthPocket. http://www.healthpocket.com/individual-health -insurance. Accessed.
Angela Golden, DNP, is the immediate past president of the American Association of Nurse Practitioners and is a family nurse practitioner in her own practice in Munds Park, AZ. She can be reached at [email protected].
1555-4155/15/$ see front matter © 2015 Elsevier, Inc. All rights reserved. http://dx.doi.org/10.1016/j.nurpra.2014.11.027
Volume 11, Issue 3, March 2015