Western Health Advantage Small Group Plan Changes 2016
In order to comply to the Standard Benefit Designs for California and the actuarial value calculations, it is required that we initiate changes to our small group benefit plans for 2016, including our direct plans (Gateway and Capital) as well as those offered through Covered California for Small Business (CCSB) and Cal-Choice. For Gateway and Capital plans, be sure to view our Benefit Comparison for 2016.
Plan Name Changes – Capital plans (mirror plans): To be consistent to plans offered in CCSB, we are required to change the plan name of the Capital plans.
- WHA Platinum 90 HMO 0/20 w/ Child Dental
- WHA Gold 80 HMO 0/35 w/ Child Dental
- WHA Silver 70 HMO 1500/45 w/ Child Dental
- WHA Silver 70 HSA HMO 2000/20% w/ Child Dental
- WHA Bronze 60 HMO 6000/70 w/ Child Dental
- WHA Bronze 60 HSA HMO 4500/40% w/ Child Dental
- WHA Bronze 60 HSA HMO 6000/0 w/ Child Dental Alternate
Copayment Changes: Due to changes in the plans’ actuarial value calculations, there are various copayment changes for services.
- Gateway/Sierra Plans –most changes affect hearing examination, emergency room and prescription copayments
- Capital/CCSB Plans –changes affect office visit, professional inpatient services and prescription copayments
Prescription benefits: There is either an introduction of a cap or a change to the cap for Tier 4 medication. This cap represents the most a member would pay for a specific drug, after the deductible has been met. In addition, the new CCSB formulary guidelines require plans to change the tier level of some drugs. Come 2016, members should review our Preferred Drug List (PDL) to determine if their medication has changed tiers.
Deductible Amounts – Gateway & Sierra Deductible Plans: We have introduced a prescription deductible separate from the medical deductible for Tiers 2, 3 and 4. To accomplish this, in most cases the medical deductible amount has been decreased by the amount of the prescription deductible, so it does not present a greater cost to the member.
| Plan | Medical Deductible | Rx Deductible (brand, non-preferred or specialty medication) |
| Gateway 4010 | $1,000/$2,000 | $250/$500 |
| Gateway 4020 | $1,750/$3,500 | $250/$500 |
| Gateway 5020 | $1,750/$3,500 | $250/$500 |
HSA-Compatible, High Deductible Health Plans (HDHP): Regulation will require that all deductible and out-of-pocket amounts be administered on an embedded basis. This means that an individual with family coverage will be limited to a specific liability amount, even when the family has not yet met the family amounts.
The affected plans, Gateway 2000 HSA (formerly G1800, see below), Gateway 1500 HSA, and Capital Silver 70 HSA HMO 2000/20%, will change from aggregate to embedded upon the group’s renewal. This will create a claims accumulation change for members this calendar year.
Deductible Amounts – HDHP: Several HDHPs have an increase to the deductible and/or out-of-pocket amounts. As a result, you will notice name changes to some HDHP plans.
For example our most popular plan, the Gateway 1800 HSA, will change to the Gateway 2000 HSA. With the deductible and out-of-pocket amounts increasing and the introduction of the Individual with Family limit, this plan will change to:
| Coverage | Deductible | OOP |
| Self-only coverage | $2,000 | $2,000 |
| Individual with family coverage | $2,600 | $2,600 |
| Family coverage | $4,000 | $4,000 |
SMALL GROUP RATES
We are happy to announce that with these benefit changes, groups will experience minor impact to their rates. On average over all plans and regions, we have an increase of 1%.
LARGE GROUP PLAN CHANGES
On the refreshing side, there are minimal changes to our large group slate of products for 2016.
Western 2800 will be eliminated: The 2016 Notice of Benefit and Payment Parameters issued by the Department of Health and Human Services provides clarification to maximum out-of-pocket (OOP) cost sharing limits. Specifically, it states that cost sharing amounts for any individual, whether enrolled in self-only or family coverage, cannot exceed the maximum out-of-pocket for self-only coverage, which as you know, is $6,600. Therefore, the Western 2800 plan, with an aggregate deductible and OOP maximum of $8,000, is no longer compliant to the Affordable Care Act (ACA) as it exceeds the $6,600 limit.
Any groups who currently offer the Western 2800 plan will be transitioned into the Western 2800B HSA (an embedded plan in which an individual with family coverage has an OOP max of $4,000) upon their renewal. Unfortunately, this change poses an adverse impact to the renewing rates as the Western 2800B HSA is a higher rater plan. The plan adjustment will be in addition to WHA’s trend and demographic changes within the group.
It is important to note WHA offers three other lower cost plan options. Please contact your WHA sales team to learn if any of your groups are affected and explore these lower cost plan options.
Eye on California’s AB1305 – limitations on cost sharing for family coverage: This proposed legislation requires the individual with family coverage amount be the greater of the self-only coverage or $2,600 (which will be indexed each year). As noted above, we are already taking this into consideration with our small group plans. However, there has been an amendment to delay this going into effect for the large group market (101+) until January 2017. We will continue to monitor this legislation and be prepared to implement as required.
OTHER CHANGES TO SMALL AND LARGE GROUP MARKETS
MyWHA Wellness: Look out for WHA’s new and improved wellness program, coming January 1, 2016. MyWHA Wellness is administered through Alere Health and includes wellness assessments and challenges, virtual coaching, seminars and the ability to track wellness credits. Note: Members will need to retake their health risk assessment using MyWHA Wellness. Previous results will not transfer to this new program.
Coaching – optional rider only: For those who have purchased the optional Healthyroads Coaching rider, this plan will be eliminated upon your renewal. Coming soon, WHA will launch a more robust coaching program through Alere, allowing employers to tailor their coaching needs to their wellness initiatives.