Covered California hosted a webinar for Certified Insurance Agents and Certified Enrollment Counselors on some of the significant changes to their individual and family plan standard benefit design for 2016. The presentation is approximately 42 minutes long and can be viewed on YouTube which can be found at the end of this post. They also created a PDF of the presentation slides that can be downloaded at the end of this post.
Variety of plan changes for 2016
Below are a few of the highlights that are discussed in more detail in the presentation.
- New health plan additions of Oscar and United Health Care and the regions where they are offering plans
- New pharmacy benefits: Four Drug Tiers and monthly cost cap per prescription. (See: Understanding the new prescription drug cost caps)
- Brand Drug deductible changed to a pharmacy deductible, allows more out-of-pocket drug costs to count toward the pharmacy deductible if the plan includes a pharmacy deductible.
- Standardized health care services to reduce consumer confusion: office visits, outpatient therapies, mental health parity compliance into a separate category.
Platinum 90 copayment plan
- Outpatient: $250 for surgery facility fee / $40 for physician. There is now a physician fee in the platinum copay plan instead of $250 copay for both benefits
- Emergency Services: $150 for facility fee /no charge for physician/surgeon fees instead of $150 copay for total ER benefit
- Inpatient Hospital Stay: $250 for facility up to 5 days /$40 for physician/surgeon fees instead of $250 copay for both benefits; same change for Mental Health, Substance Use, and Pregnancy.
- Tier 4 drugs: Added cap of $250 per prescription
Platinum PPO coinsurance plan
- Emergency Services: $150 for facility fee /10% for physician/surgeon fees instead of $150 copay for total ER benefit
- Tier 4 drugs: Added cap of $250 per prescription
- Gold 80 plans have slightly higher copayments and smaller maximum out-of-pocket amount from 2015.
Gold HMO Gold copayment plans
- Primary care visit: $35. New cost-share also applies to Mental Health/Substance Use Disorder outpatient office visits.
- Outpatient Services: $600 for facility / $55 for physician/surgeon fees instead of $600 copay for both benefits.
- Emergency Services: $250 for facility /no charge for physician/surgeon fees instead of $250 copay for total ER benefit
- Inpatient Hospital Stay: $600 for facility /$55 for physician/surgeon fees instead of $600 copay for both benefits; same change for Inpatient Mental Health, Substance Use, and Pregnancy.
- Tier 4 drugs: Added cap of $250 per prescription
Gold PPO Gold coinsurance plans
- Primary care visit: $35. New cost-share also applies to Mental Health/Substance Use Disorder outpatient office visits.
- Emergency Services: $250 for facility fee /20% for physician/surgeon fees instead of $250 copay for both benefits
- Tier 4 drugs: Added cap of $250 per prescription
Silver Plans
Silver 70 coinsurance and copayment plan designs have been combined into a single plan design.
- Imaging: $250 copay; deductible no longer applies
- Emergency Services: $250 for facility /$50 for physician/surgeon fees instead of $250 copay for total ER benefit
- Inpatient Hospital Services: Coinsurance is the same but the deductible now applies to both physician/surgeon fees and facility fee; same change for inpatient Mental Health, Substance Use, and Pregnancy Delivery physician fee
- Home Health: $45 copayment
- Tier 4 drugs: Added cap of $250 per prescription
Many of the adjustments to the Silver plan design have been transferred to the Enhanced Silver plans at reduced cost sharing amounts.
Silver 94
- Tier 4 drugs: Added cap of $150 per prescription
- Emergency Services: $30 for facility /$25 for physician/surgeon fees instead of $25 copay for total ER benefit
- Inpatient hospital stay: Deductible applies to both facility and physician/surgeon fees; same change for Inpatient Mental Health, Substance Use, and Pregnancy Delivery physician fee
- Skilled Nursing Facility: Deductible now applies to Skilled Nursing Facility
Silver 87
- Tier 4 drugs: Added cap of $150 per prescription
- Emergency Services: $75 for facility /$40 for physician/surgeon fee (both after deductible) instead of $75 copay for total ER benefit
- Inpatient hospital stay: Deductible applies to physician/surgeon fees; same change for Inpatient Mental Health, Substance Use, and Pregnancy Delivery physician fee.
Silver 73
- Increases in deductible and maximum out-of-pocket amounts and inpatient hospital and physician fee.
- Tier 4 drugs: Added cap of $250 per prescription.
- Emergency Services: $250 for facility /$50 for physician/surgeon fees instead of $250 copay for total ER benefit
Bronze 60
Has a new pharmacy deductible in addition to a medical deductible. There will be no coinsurance after the deductible of $6,000 is met. Consumers will see no relief of health care expenses until the maximum-out-pocket of $6,500 is met. The loss of coinsurance was in order to implement a pharmacy deductible and prescription drug caps within the Bronze plans. Primary care visits of $70 copay before deductible, in addition to three specialist visits at $90 before the deductible. Lab tests have a $40 copayment and are not subject to reaching the deductible amount first.
- Out-of-Pocket Maximum: $6,500
- Medical Deductible: $6,000 for the medical deductible; Member pays 100% of the cost of services until MOOP is met. For all services with a previous member cost-share of 30% coinsurance or copay after deductible: member cost share is now “100%” after deductible until the MOOP of $6,500 is met.
- Pharmacy Deductible: $500 for the pharmacy deductible; Member pays 100% of the cost of services until MOOP is met. For all services with a previous member cost-share of 30% coinsurance or copay after deductible: member cost share is now “100%” after deductible until the MOOP of $6,500 is met.
- Tier 1 – 4 drugs: 100% up to $500 per prescription after deductible
- Lab Tests: $40 (no longer subject to deductible)
- Specialist Visits: $90; Deductible applies after three primary care/specialist visits at the copay amount have been accumulated
- Outpatient Rehab: $70; deductible no longer applies
For all the specific changes to all plans view the webinar or download the slide deck of the presentation below.
2016 Covered California Plan Updates Presentation PDF Slide Deck
YouTube Recording – Webinar of 2016 Plan Changes and Updates
