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How to Efficiently and Effectively Help Consumers Navigate Plan Selection

The document provides guidelines on assisting consumers in selecting health plans from the marketplace, detailing trends, plan elements, and comparisons of Qualified Health Plans (QHPs). It includes information on premiums, cost-sharing, benefits, and an interactive exercise for analyzing specific consumer scenarios. Additionally, it emphasizes the importance of understanding plan networks and the confusion around provider directories.

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© 2015 Enroll America and Get Covered America EnrollAmerica.org | GetCoveredAmerica.org Dave Chandra, Senior Policy Analyst, Center on Budget and Policy Priorities | 06.11.15 How to Effectively and Efficiently Help Consumers Navigate Plan Selection
1.  Trends in Marketplace QHPs 2.  Analyzing QHPs in your Region 3.  Assisting Consumers in Plan Selection - Demonstration 4.  Assisting Consumers in Plan Selection - Interactive exercise 2 Presentation Overview
Trends in Marketplace QHPs
Overview of Marketplace Health Plan Elements 1.  Premium 2.  Cost Sharing – Deductible – Co-pays/Co-insurance – Out-of-Pocket Maximum 3.  Benefits/Drug Formulary 4.  Provider Network 4
Copays   Fixed  dollar  amount  per  visit  or  per  day   paid  by  the  enrollee.   Coinsurance   Percent  of  a  medical  fee/bill  paid  by  the   enrollee   Copays and Coinsurance Overview Source:  HealthCare.gov,  Kaiser  Permanente  KP  VA  0/20/Dental  and  KP  VA   1000/20/Dental  Gold  Plans  for  Fairfax  County,  VA   5
Increase of Coinsurance in QHPs 6 Source:  HealthCare.gov,  Highmark  Health  Savings  Blue  PPO  2750  Silver  plan  for  Westmoreland  County,  PA  
Copays and Coinsurance Prescription Drug Copay Tiers 7 Source:  HealthCare.gov,  UPMC  Advantage  Value  Silver  Select  plan  for  Westmoreland  County,  PA  
Additional Tiering of Prescription Drug Copays 8 Source:  Summary  of  Benefits  and  Coverage  for  Humana  Silver  4600/AusRn   HMOx  in  Travis  County,  TX  
Additional Tiering of Prescription Drug Copays 9 SourceHumana  Silver  4600/AusRn  HMOx  in  Travis  County,  TX  
Services/Copays Exempt from the Deductible 10 Source:  HealthCare.gov,  Anthem  HealthKeepers  Silver  X  3350  15  plan  for  Fairfax  County,  VA   deduc%ble   applies  
Services/Copays Exempt from the Deductible 11 Source:  HealthCare.gov,  Anthem  HealthKeepers  Silver  X  3350  15  plan  for  Fairfax  County,  VA   deduc%ble   does  not   apply  
HSA vs. Non-HSA Plans 12 Source:  HealthCare.gov,  Kaiser  Permanente  Bronze  4500/5-­‐/HAS/Dental/Ped   Dental  and  Bronze  4500/5-­‐/Dental/Ped  Dental    plans  in  Fairfax  County  VA  
“3 Step Copay”(Copay/Deductible/Coinsurance) 13 Source:  Summary  of  Benefits  and  Coverage  for  Anthem  HealthKeepers  Bronze  X   4500  35  in  Fairfax  County,  VA  
“3 Step Copay”(Copay/Deductible/Coinsurance) 14 Source:  HealthCare.gov,  Anthem  HealthKeepers  Bronze  X  4500  35  in  Fairfax   County,  VA  
Cost Sharing Reduction (CSR) Plans 15 FPL%   Silver  Plan  Eligibility   <  150%   94%  variant   151%  -­‐  200%   87%  variant   201%  -­‐  250%   73%  variant   >  251%   70%  base  plan  
Cost Sharing Reduction (CSR) Plans 16
Cost Sharing Reduction (CSR) Plans 17
Essential Health Benefits 18
Pediatric Dental Benefit Source:  healthcare.gov,  InnovaRon  Health-­‐Aetna  INOVA  Silver  $10  Copay  plan  and   Kaiser  Permanente  VA  Silver  1750/25%/HSA/Dental/Ped  Dental  plan  for  Fairfax   County,  VA   19
Essential Health Benefits Other Covered Services 20 Source:  Summary  of  Benefits  and  Coverage  for  New  Mexico  Health  ConnecRons   Healthy  Connect  Bronze  HMO  in  Albuquerque,  NM  
21 Type   Name   PCP   Required?   Referrals   Required?   Out-­‐of-­‐ Network   Coverage?   PPO   Preferred  Provider  Organiza%on   No   No   Yes   POS   Point  of  Service   Yes   Maybe   Yes   HMO   Health  Maintenance  Organiza%on   Yes   Yes   No*   EPO   Exclusive  Provider  Organiza%on   No   No   No*   *except  for  emergency  care   Health Plan Network Types
QHPs with Narrow Provider Networks Health plans are using narrow provider networks to keep costs down 22
QHPs with Tiered Networks 23 Source:  Plan  Brochure  for  Independence  Blue  Cross  HMO  Silver  ProacRve  Plan   in  Philadelphia  County,  PA  
Tiered Provider Networks 24 Source:  Summary  of  Benefits  and  Coverage  for  Independence  Blue  Cross  HMO   Silver  ProacRve  Plan  in  Philadelphia  County,  PA  
Confusion and Inaccuracies in Provider Directories 25 Source:  HealthCare.gov  and  Provider  Search  site  for  BlueCross  BlueShield  BlueCare  SoluRons  Plan  in  Sedgwick  County,   KS    
Preparing for Open Enrollment III Analyzing QHPs in your Region
Comparing 2014 and 2015 Marketplace Plans 27 Source:  ProPublica,    h`p://projects.propublica.org/aca-­‐enrollment/#    
Comparing 2014 and 2015 Marketplace Plans 28 Source:  ProPublica,    h`p://projects.propublica.org/aca-­‐enrollment/#    
Analyzing Changes to QHPs in Your Region 29
Comparing QHPs in Your Region 30
Comparing QHPs in Your Region – Additional Benefits 31 Service   CareFirst  BCBS   Innova%on   Health   Kaiser   Permanente   Acupuncture   Bariatric  Surgery   X   X   ChiropracCc  Care     X   X   X   CosmeCc  Surgery   Coverage  Outside  the  U.S.   X   Dental  Care  for  Adults   X   Dental  Care  for  Children   X   Hearing  Aids   Hearing  Aids   InferClity  Treatment     X   Long-­‐Term/Custodial   Nursing  Home  Care   Non-­‐Emergency  Care  when   Traveling  Outside  the  US   X   Private-­‐Duty  Nursing     X   X   X   Eye  Care  for  Adults   X   X   RouCne  Foot  Care   RouCne  Hearing  Tests   X   Weight  Loss  Programs  
Demonstration Assisting Consumers in Plan Selection
CBPP Marketplace Plan Comparison Worksheet available  at:     hQp:// www.healthreformbeyondthebasics.org/ marketplace-­‐plan-­‐comparison-­‐worksheet/     33
Scenario 1: James and Ann (married couple) 34 James   Ann   Age   52   45   County   Oakland  County,  MI   Zip  Code   48324   Income   $0   $23,000   Federal  Poverty  Level   144%   Employer  coverage?   no   no   Insurance  status   uninsured   uninsured  
Scenario 1: James and Ann (married couple) 35
Scenario 1: James and Ann (married couple) 36
Scenario 1: James and Ann (married couple) 37
Scenario 1: James and Ann (married couple) 38 Applicant  Name:     Tax  Credit  (monthly):     Date:   Number  of  people  in  the  plan:       Eligible  for  cost-­‐sharing  reducCons?     □  No        □  73%        □  87%        □  94%           Marketplace  Plan  Comparison  Worksheet   Option 1 Option 2 Option 3 Insurance company Health plan name Metal tier (Bronze, Silver, Gold, Platinum) Plan type (HMO, PPO, POS, EPO, or other) Monthly premium (after tax credit)
Scenario 1: James and Ann (married couple) 39 Applicant  Name:        James and Ann Tax  Credit  (monthly):     $549.66     Date:   6/11/15   Number  of  people  in  the  plan:       2 Eligible  for  cost-­‐sharing  reducCons?     □  No        □  73%        □  87%        ý  94%           Marketplace  Plan  Comparison  Worksheet   Option 1 Option 2 Option 3 Insurance company Health plan name Metal tier (Bronze, Silver, Gold, Platinum) Plan type (HMO, PPO, POS, EPO, or other) Monthly premium (after tax credit)
40 Copays/Coinsurance Amount Amount Amount Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes) Primary Care Provider (PCP) visit Specialist visit Prescriptions Generic drugs Preferred brand name drugs Non-preferred brand name drugs Specialty drugs Emergency Room (ER) visit Inpatient hospital stay Other service: Other service: Option 1 Option 2 Option 3 Insurance company Health plan name Plan type (HMO, PPO, POS, EPO, or other) Monthly premium (after tax credit) Deductible (medical/drug or combined) Out-of-Pocket Maximum (OOP Max) Health Care Providers In Network/Covered? In Network/Covered? In Network/Covered? Current doctor/provider: Other provider or hospital: Current prescription drugs: Scenario 1: James and Ann (married couple)
41 Copays/Coinsurance Amount Amount Amount Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes) Primary Care Provider (PCP) visit Specialist visit Prescriptions Generic drugs Preferred brand name drugs Non-preferred brand name drugs Specialty drugs Emergency Room (ER) visit Inpatient hospital stay Other service: Laboratory Services Other service: X-rays and Diagnostic Imaging Option 1 Option 2 Option 3 Insurance company Health plan name Plan type (HMO, PPO, POS, EPO, or other) Monthly premium (after tax credit) Deductible (medical/drug or combined) Out-of-Pocket Maximum (OOP Max) Health Care Providers In Network/Covered? In Network/Covered? In Network/Covered? Current doctor/provider: Other provider or hospital: Current prescription drugs: Scenario 1: James and Ann (married couple)
Scenario 1: James and Ann (married couple)
Scenario 1: James and Ann (married couple)
44 Scenario 1: James and Ann (married couple)
45 Scenario 1: James and Ann (married couple)
46 Scenario 1: James and Ann (married couple)
47 Copays/Coinsurance Amount Amount Amount Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes) Primary Care Provider (PCP) visit Specialist visit Prescriptions Generic drugs Preferred brand name drugs Non-preferred brand name drugs Specialty drugs Emergency Room (ER) visit Inpatient hospital stay Other service: Laboratory Services Other service: X-rays and Diagnostic Imaging Option 1 Option 2 Option 3 Insurance company Health plan name Plan type (HMO, PPO, POS, EPO, or other) Monthly premium (after tax credit) Deductible (medical/drug or combined) Out-of-Pocket Maximum (OOP Max) Health Care Providers In Network/Covered? In Network/Covered? In Network/Covered? Current doctor/provider: Other provider or hospital: Current prescription drugs: Scenario 1: James and Ann (married couple)
48 Copays/Coinsurance Amount Amount Amount Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes) Primary Care Provider (PCP) visit Specialist visit Prescriptions Generic drugs Preferred brand name drugs Non-preferred brand name drugs Specialty drugs Emergency Room (ER) visit Inpatient hospital stay Other service: Laboratory Services Other service: X-rays and Diagnostic Imaging Option 1 Option 2 Option 3 Insurance company Humana Health plan name Silver 4600/Detroit HMOx Plan type (HMO, PPO, POS, EPO, or other) HMO Monthly premium (after tax credit) $36 Deductible (medical/drug or combined) $1,000 (combined) Out-of-Pocket Maximum (OOP Max) $1,500 Health Care Providers In Network/Covered? In Network/Covered? In Network/Covered? Current doctor/provider: Other provider or hospital: Current prescription drugs: Scenario 1: James and Ann (married couple)
49 Copays/Coinsurance Amount Amount Amount Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes) Primary Care Provider (PCP) visit $25 Specialist visit $35 Prescriptions Generic drugs $17* Preferred brand name drugs $50 ü Non-preferred brand name drugs 50% ü Specialty drugs 50% ü Emergency Room (ER) visit 20% ü Inpatient hospital stay 20% ü Other service: Laboratory Services 20% ü Other service: X-rays and Diagnostic Imaging 20% ü Option 1 Option 2 Option 3 Insurance company Humana Health plan name Silver 4600/Detroit HMOx Plan type (HMO, PPO, POS, EPO, or other) HMO Monthly premium (after tax credit) $36 Deductible (medical/drug or combined) $1,000 (combined) Out-of-Pocket Maximum (OOP Max) $1,500 Health Care Providers In Network/Covered? In Network/Covered? In Network/Covered? Current doctor/provider: Other provider or hospital: Current prescription drugs: Scenario 1: James and Ann (married couple)
50 Copays/Coinsurance Amount Amount Amount Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes) Primary Care Provider (PCP) visit $25 $10 Specialist visit $35 $30 ü Prescriptions Generic drugs $17* 1A - $4, 1B - $20 Preferred brand name drugs $50 ü 25% ü Non-preferred brand name drugs 50% ü 50% ü Specialty drugs 50% ü 20% ü Emergency Room (ER) visit 20% ü $100/10% ü Inpatient hospital stay 20% ü 10% ü Other service: Laboratory Services 20% ü no charge ü Other service: X-rays and Diagnostic Imaging 20% ü 10% ü Option 1 Option 2 Option 3 Insurance company Humana Blue Care Network of MI Health plan name Silver 4600/Detroit HMOx Metro Detroit HMO Silver Plan type (HMO, PPO, POS, EPO, or other) HMO HMO Monthly premium (after tax credit) $36 $73 Deductible (medical/drug or combined) $1,000 (combined) $350 (combined) Out-of-Pocket Maximum (OOP Max) $1,500 $1,000 Health Care Providers In Network/Covered? In Network/Covered? In Network/Covered? Current doctor/provider: Other provider or hospital: Current prescription drugs: Scenario 1: James and Ann (married couple)
51 Copays/Coinsurance Amount Amount Amount Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes) Primary Care Provider (PCP) visit $25 $10 $10 n/a Specialist visit $35 $30 ü $20 n/a Prescriptions Generic drugs $17* 1A - $4, 1B - $20 no charge n/a Preferred brand name drugs $50 ü 25% ü $15 n/a Non-preferred brand name drugs 50% ü 50% ü $50 n/a Specialty drugs 50% ü 20% ü $50 n/a Emergency Room (ER) visit 20% ü $100/10% ü $75 n/a Inpatient hospital stay 20% ü 10% ü no charge n/a Other service: Laboratory Services 20% ü no charge ü no charge n/a Other service: X-rays and Diagnostic Imaging 20% ü 10% ü $20 n/a Option 1 Option 2 Option 3 Insurance company Humana Blue Care Network of MI Total Health Care USA Health plan name Silver 4600/Detroit HMOx Metro Detroit HMO Silver Totally You (Silver) Plan type (HMO, PPO, POS, EPO, or other) HMO HMO HMO Monthly premium (after tax credit) $36 $73 $96 Deductible (medical/drug or combined) $1,000 (combined) $350 (combined) $0 Out-of-Pocket Maximum (OOP Max) $1,500 $1,000 $1,500 Health Care Providers In Network/Covered? In Network/Covered? In Network/Covered? Current doctor/provider: Other provider or hospital: Current prescription drugs: Scenario 1: James and Ann (married couple)
52 Copays/Coinsurance Amount Amount Amount Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes) Primary Care Provider (PCP) visit $25 $10 $10 n/a Specialist visit $35 $30 ü $20 n/a Prescriptions Generic drugs $17* 1A - $4, 1B - $20 no charge n/a Preferred brand name drugs $50 ü 25% ü $15 n/a Non-preferred brand name drugs 50% ü 50% ü $50 n/a Specialty drugs 50% ü 20% ü $50 n/a Emergency Room (ER) visit 20% ü $100/10% ü $75 n/a Inpatient hospital stay 20% ü 10% ü no charge n/a Other service: Laboratory Services 20% ü no charge ü no charge n/a Other service: X-rays and Diagnostic Imaging 20% ü 10% ü $20 n/a Option 1 Option 2 Option 3 Insurance company Humana Blue Care Network of MI Total Health Care USA Health plan name Silver 4600/Detroit HMOx Metro Detroit HMO Silver Totally You (Silver) Plan type (HMO, PPO, POS, EPO, or other) HMO HMO HMO Monthly premium (after tax credit) $36 $73 $96 Deductible (medical/drug or combined) $1,000 (combined) $350 (combined) $0 Out-of-Pocket Maximum (OOP Max) $1,500 $1,000 $1,500 Health Care Providers In Network/Covered? In Network/Covered? In Network/Covered? Current doctor/provider: D. Willens, MD Other provider or hospital: Current prescription drugs: Scenario 1: James and Ann (married couple)
53 Copays/Coinsurance Amount Amount Amount Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes) Primary Care Provider (PCP) visit $25 $10 $10 n/a Specialist visit $35 $30 ü $20 n/a Prescriptions Generic drugs $17* 1A - $4, 1B - $20 no charge n/a Preferred brand name drugs $50 ü 25% ü $15 n/a Non-preferred brand name drugs 50% ü 50% ü $50 n/a Specialty drugs 50% ü 20% ü $50 n/a Emergency Room (ER) visit 20% ü $100/10% ü $75 n/a Inpatient hospital stay 20% ü 10% ü no charge n/a Other service: Laboratory Services 20% ü no charge ü no charge n/a Other service: X-rays and Diagnostic Imaging 20% ü 10% ü $20 n/a Option 1 Option 2 Option 3 Insurance company Humana Blue Care Network of MI Total Health Care USA Health plan name Silver 4600/Detroit HMOx Metro Detroit HMO Silver Totally You (Silver) Plan type (HMO, PPO, POS, EPO, or other) HMO HMO HMO Monthly premium (after tax credit) $36 $73 $96 Deductible (medical/drug or combined) $1,000 (combined) $350 (combined) $0 Out-of-Pocket Maximum (OOP Max) $1,500 $1,000 $1,500 Health Care Providers In Network/Covered? In Network/Covered? In Network/Covered? Current doctor/provider: D. Willens, MD Other provider or hospital: # of oncologists Current prescription drugs: Scenario 1: James and Ann (married couple)
54 Copays/Coinsurance Amount Amount Amount Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes) Primary Care Provider (PCP) visit $25 $10 $10 n/a Specialist visit $35 $30 ü $20 n/a Prescriptions Generic drugs $17* 1A - $4, 1B - $20 no charge n/a Preferred brand name drugs $50 ü 25% ü $15 n/a Non-preferred brand name drugs 50% ü 50% ü $50 n/a Specialty drugs 50% ü 20% ü $50 n/a Emergency Room (ER) visit 20% ü $100/10% ü $75 n/a Inpatient hospital stay 20% ü 10% ü no charge n/a Other service: Laboratory Services 20% ü no charge ü no charge n/a Other service: X-rays and Diagnostic Imaging 20% ü 10% ü $20 n/a Option 1 Option 2 Option 3 Insurance company Humana Blue Care Network of MI Total Health Care USA Health plan name Silver 4600/Detroit HMOx Metro Detroit HMO Silver Totally You (Silver) Plan type (HMO, PPO, POS, EPO, or other) HMO HMO HMO Monthly premium (after tax credit) $36 $73 $96 Deductible (medical/drug or combined) $1,000 (combined) $350 (combined) $0 Out-of-Pocket Maximum (OOP Max) $1,500 $1,000 $1,500 Health Care Providers In Network/Covered? In Network/Covered? In Network/Covered? Current doctor/provider: D. Willens, MD Other provider or hospital: # of oncologists Current prescription drugs: metformin Scenario 1: James and Ann (married couple)
55 Scenario 1: James and Ann (married couple)
56 Scenario 1: James and Ann (married couple)
57 Scenario 1: James and Ann (married couple)
58 Scenario 1: James and Ann (married couple)
59 Scenario 1: James and Ann (married couple)
60 Scenario 1: James and Ann (married couple)
61 Scenario 1: James and Ann (married couple)
62 Copays/Coinsurance Amount Amount Amount Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes) Primary Care Provider (PCP) visit $25 $10 $10 n/a Specialist visit $35 $30 ü $20 n/a Prescriptions Generic drugs $17* 1A - $4, 1B - $20 no charge n/a Preferred brand name drugs $50 ü 25% ü $15 n/a Non-preferred brand name drugs 50% ü 50% ü $50 n/a Specialty drugs 50% ü 20% ü $50 n/a Emergency Room (ER) visit 20% ü $100/10% ü $75 n/a Inpatient hospital stay 20% ü 10% ü no charge n/a Other service: Laboratory Services 20% ü no charge ü no charge n/a Other service: X-rays and Diagnostic Imaging 20% ü 10% ü $20 n/a Option 1 Option 2 Option 3 Insurance company Humana Blue Care Network of MI Total Health Care USA Health plan name Silver 4600/Detroit HMOx Metro Detroit HMO Silver Totally You (Silver) Plan type (HMO, PPO, POS, EPO, or other) HMO HMO HMO Monthly premium (after tax credit) $36 $73 $96 Deductible (medical/drug or combined) $1,000 (combined) $350 (combined) $0 Out-of-Pocket Maximum (OOP Max) $1,500 $1,000 $1,500 Health Care Providers In Network/Covered? In Network/Covered? In Network/Covered? Current doctor/provider: D. Willens, MD Other provider or hospital: # of oncologists Current prescription drugs: metformin Scenario 1: James and Ann (married couple)
63 Copays/Coinsurance Amount Amount Amount Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes) Primary Care Provider (PCP) visit $25 $10 $10 n/a Specialist visit $35 $30 ü $20 n/a Prescriptions Generic drugs $17* 1A - $4, 1B - $20 no charge n/a Preferred brand name drugs $50 ü 25% ü $15 n/a Non-preferred brand name drugs 50% ü 50% ü $50 n/a Specialty drugs 50% ü 20% ü $50 n/a Emergency Room (ER) visit 20% ü $100/10% ü $75 n/a Inpatient hospital stay 20% ü 10% ü no charge n/a Other service: Laboratory Services 20% ü no charge ü no charge n/a Other service: X-rays and Diagnostic Imaging 20% ü 10% ü $20 n/a Option 1 Option 2 Option 3 Insurance company Humana Blue Care Network of MI Total Health Care USA Health plan name Silver 4600/Detroit HMOx Metro Detroit HMO Silver Totally You (Silver) Plan type (HMO, PPO, POS, EPO, or other) HMO HMO HMO Monthly premium (after tax credit) $36 $73 $96 Deductible (medical/drug or combined) $1,000 (combined) $350 (combined) $0 Out-of-Pocket Maximum (OOP Max) $1,500 $1,000 $1,500 Health Care Providers In Network/Covered? In Network/Covered? In Network/Covered? Current doctor/provider: D. Willens, MD û û û Other provider or hospital: # of oncologists Current prescription drugs: metformin Scenario 1: James and Ann (married couple)
64 Scenario 1: James and Ann (married couple)
65 Scenario 1: James and Ann (married couple)
66 Copays/Coinsurance Amount Amount Amount Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes) Primary Care Provider (PCP) visit $25 $10 $10 n/a Specialist visit $35 $30 ü $20 n/a Prescriptions Generic drugs $17* 1A - $4, 1B - $10 no charge n/a Preferred brand name drugs $50 ü 25% ü $15 n/a Non-preferred brand name drugs 50% ü 50% ü $50 n/a Specialty drugs 50% ü 20% ü $50 n/a Emergency Room (ER) visit 20% ü $100/10% ü $75 n/a Inpatient hospital stay 20% ü 10% ü no charge n/a Other service: Laboratory Services 20% ü no charge ü no charge n/a Other service: X-rays and Diagnostic Imaging 20% ü 10% ü $20 n/a Option 1 Option 2 Option 3 Insurance company Humana Blue Care Network of MI Total Health Care USA Health plan name Silver 4600/Detroit HMOx Metro Detroit HMO Silver Totally You (Silver) Plan type (HMO, PPO, POS, EPO, or other) HMO HMO HMO Monthly premium (after tax credit) $36 $73 $96 Deductible (medical/drug or combined) $1,000 (combined) $350 (combined) $0 Out-of-Pocket Maximum (OOP Max) $1,500 $1,000 $1,500 Health Care Providers In Network/Covered? In Network/Covered? In Network/Covered? Current doctor/provider: D. Willens, MD û û û Other provider or hospital: # of oncologists Current prescription drugs: metformin Scenario 1: James and Ann (married couple)
67 Copays/Coinsurance Amount Amount Amount Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes) Primary Care Provider (PCP) visit $25 $10 $10 n/a Specialist visit $35 $30 ü $20 n/a Prescriptions Generic drugs $17* 1A - $4, 1B - $20 no charge n/a Preferred brand name drugs $50 ü 25% ü $15 n/a Non-preferred brand name drugs 50% ü 50% ü $50 n/a Specialty drugs 50% ü 20% ü $50 n/a Emergency Room (ER) visit 20% ü $100/10% ü $75 n/a Inpatient hospital stay 20% ü 10% ü no charge n/a Other service: Laboratory Services 20% ü no charge ü no charge n/a Other service: X-rays and Diagnostic Imaging 20% ü 10% ü $20 n/a Option 1 Option 2 Option 3 Insurance company Humana Blue Care Network of MI Total Health Care USA Health plan name Silver 4600/Detroit HMOx Metro Detroit HMO Silver Totally You (Silver) Plan type (HMO, PPO, POS, EPO, or other) HMO HMO HMO Monthly premium (after tax credit) $36 $73 $96 Deductible (medical/drug or combined) $1,000 (combined) $350 (combined) $0 Out-of-Pocket Maximum (OOP Max) $1,500 $1,000 $1,500 Health Care Providers In Network/Covered? In Network/Covered? In Network/Covered? Current doctor/provider: D. Willens, MD û û û Other provider or hospital: # of oncologists 33 (10 mi.), 69 (20 mi.) 49 (10 mi.), 174 (25 mi.) 17 (10 mi.), 96 (25 mi.) Current prescription drugs: metformin Scenario 1: James and Ann (married couple)
68 Scenario 1: James and Ann (married couple)
69 Scenario 1: James and Ann (married couple)
70 Scenario 1: James and Ann (married couple)
71 Scenario 1: James and Ann (married couple)
72 Scenario 1: James and Ann (married couple)
73 Copays/Coinsurance Amount Amount Amount Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes) Primary Care Provider (PCP) visit $25 $10 $10 n/a Specialist visit $35 $30 ü $20 n/a Prescriptions Generic drugs $17* 1A - $4, 1B - $20 no charge n/a Preferred brand name drugs $50 ü 25% ü $15 n/a Non-preferred brand name drugs 50% ü 50% ü $50 n/a Specialty drugs 50% ü 20% ü $50 n/a Emergency Room (ER) visit 20% ü $100/10% ü $75 n/a Inpatient hospital stay 20% ü 10% ü no charge n/a Other service: Laboratory Services 20% ü no charge ü no charge n/a Other service: X-rays and Diagnostic Imaging 20% ü 10% ü $20 n/a Option 1 Option 2 Option 3 Insurance company Humana Blue Care Network of MI Total Health Care USA Health plan name Silver 4600/Detroit HMOx Metro Detroit HMO Silver Totally You (Silver) Plan type (HMO, PPO, POS, EPO, or other) HMO HMO HMO Monthly premium (after tax credit) $36 $73 $96 Deductible (medical/drug or combined) $1,000 (combined) $350 (combined) $0 Out-of-Pocket Maximum (OOP Max) $1,500 $1,000 $1,500 Health Care Providers In Network/Covered? In Network/Covered? In Network/Covered? Current doctor/provider: D. Willens, MD û û û Other provider or hospital: # of oncologists 33 (10 mi.), 69 (20 mi.) 49 (10 mi.), 174 (25 mi.) 17 (10 mi.), 96 (25 mi.) Current prescription drugs: metformin Scenario 1: James and Ann (married couple)
74 Copays/Coinsurance Amount Amount Amount Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes) Primary Care Provider (PCP) visit $25 $10 $10 n/a Specialist visit $35 $30 ü $20 n/a Prescriptions Generic drugs $17* 1A - $4, 1B - $20 no charge n/a Preferred brand name drugs $50 ü 25% ü $15 n/a Non-preferred brand name drugs 50% ü 50% ü $50 n/a Specialty drugs 50% ü 20% ü $50 n/a Emergency Room (ER) visit 20% ü $100/10% ü $75 n/a Inpatient hospital stay 20% ü 10% ü no charge n/a Other service: Laboratory Services 20% ü no charge ü no charge n/a Other service: X-rays and Diagnostic Imaging 20% ü 10% ü $20 n/a Option 1 Option 2 Option 3 Insurance company Humana Blue Care Network of MI Total Health Care USA Health plan name Silver 4600/Detroit HMOx Metro Detroit HMO Silver Totally You (Silver) Plan type (HMO, PPO, POS, EPO, or other) HMO HMO HMO Monthly premium (after tax credit) $36 $73 $96 Deductible (medical/drug or combined) $1,000 (combined) $350 (combined) $0 Out-of-Pocket Maximum (OOP Max) $1,500 $1,000 $1,500 Health Care Providers In Network/Covered? In Network/Covered? In Network/Covered? Current doctor/provider: D. Willens, MD û û û Other provider or hospital: # of oncologists 33 (10 mi.), 69 (20 mi.) 49 (10 mi.), 174 (25 mi.) 17 (10 mi.), 96 (25 mi.) Current prescription drugs: metformin yes (tier 1 & 2) yes (tier 1A) yes (tier 1 & 3) Scenario 1: James and Ann (married couple)
•  Cheapest monthly payment? •  Manageable deductible? •  Low copays/coinsurance? •  Having “first dollar” coverage? (i.e. some services exempt from the deductible)? •  Prescription drugs covered? •  Current doctor in network? •  Size of network? Identify James’s and Ann’s Priorities for Insurance 75
76 *Jennifer  can  be  claimed  as  a  tax  dependent  as  a  qualifying  relaRve   because  she  is  receives  more  than  half  of  her  support  from  her   parents  and  makes  less  than  $3,950   Scenario 2: the Green Family (family of 5) Rosa   Dan   Jennifer*   Kristy   Cara   Age   43   43   20   16   10   County  (Zip  Code)   Greenville  County,  SC  (29607)   Income   $25,000   $20,000   $0   $0   $0   FPL   161  %FPL   Employer  coverage   no   no   no   no   no   Insurance  status   uninsured   uninsured   uninsured   on  Medicaid   on  Medicaid  
77 Scenario 2: the Green Family (family of 5)
Scenario 2: the Green Family (family of 5) 78 Applicant  Name:         Tax  Credit  (monthly):     Date:   Number  of  people  in  the  plan:       Eligible  for  cost-­‐sharing  reducCons?     □  No        □  73%        □  87%        □  94%           Marketplace  Plan  Comparison  Worksheet   Option 1 Option 2 Option 3 Insurance company Health plan name Metal tier (Bronze, Silver, Gold, Platinum) Plan type (HMO, PPO, POS, EPO, or other) Monthly premium (after tax credit)
Scenario 2: the Green Family (family of 5) 79 Applicant  Name:     Rosa, Dan, Jennifer Tax  Credit  (monthly):     $548.80   Date:   6/11/15   Number  of  people  in  the  plan:       3 Eligible  for  cost-­‐sharing  reducCons?     □  No        □  73%        ý  87%        □  94%           Marketplace  Plan  Comparison  Worksheet   Option 1 Option 2 Option 3 Insurance company Health plan name Metal tier (Bronze, Silver, Gold, Platinum) Plan type (HMO, PPO, POS, EPO, or other) Monthly premium (after tax credit)
Scenario 2: the Green Family (family of 5) 80
Scenario 2: the Green Family (family of 5) 81
Scenario 2: the Green Family (family of 5) 82
Scenario 2: the Green Family (family of 5) 83
84 Copays/Coinsurance Amount Amount Amount Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes) Primary Care Provider (PCP) visit Specialist visit Prescriptions Generic drugs Preferred brand name drugs Non-preferred brand name drugs Specialty drugs Emergency Room (ER) visit Inpatient hospital stay Option 1 Option 2 Option 3 Insurance company Health plan name Plan type (HMO, PPO, POS, EPO, or other) Monthly premium (after tax credit) Deductible (in-network/out-of-network) OOP Maximum (in-network/out-of-network) Other Considerations Other Consideration: Other Consideration: Other Consideration: Scenario 2: the Green Family (family of 5)
85 Copays/Coinsurance Amount Amount Amount Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes) Primary Care Provider (PCP) visit no charge ü Specialist visit no charge ü Prescriptions Generic drugs no charge ü Preferred brand name drugs no charge ü Non-preferred brand name drugs no charge ü Specialty drugs no charge ü Emergency Room (ER) visit no charge ü Inpatient hospital stay no charge ü Option 1 Option 2 Option 3 Insurance company Consumers’ Choice Health plan name Bronze HDP 1 Plan type (HMO, PPO, POS, EPO, or other) EPO Monthly premium (after tax credit) $0 Deductible (in-network/out-of-network) $11,000 OOP Maximum (in-network/out-of-network) $11,000 Other Considerations Other Consideration: Other Consideration: Other Consideration: Scenario 2: the Green Family (family of 5)
86 Copays/Coinsurance Amount Amount Amount Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes) Primary Care Provider (PCP) visit no charge ü $40 Specialist visit no charge ü $150 Prescriptions Generic drugs no charge ü $20 Preferred brand name drugs no charge ü $80 Non-preferred brand name drugs no charge ü $150 Specialty drugs no charge ü 20% ü Emergency Room (ER) visit no charge ü 20% ü Inpatient hospital stay no charge ü 20% ü Option 1 Option 2 Option 3 Insurance company Consumers’ Choice Consumers’ Choice Health plan name Bronze HDP 1 Bronze 10 Plan type (HMO, PPO, POS, EPO, or other) EPO EPO Monthly premium (after tax credit) $0 $13 Deductible (in-network/out-of-network) $11,000 $12,600 OOP Maximum (in-network/out-of-network) $11,000 $13,200 Other Considerations Other Consideration: Other Consideration: Other Consideration: Scenario 2: the Green Family (family of 5)
87 Copays/Coinsurance Amount Amount Amount Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes) Primary Care Provider (PCP) visit no charge ü $40 T1: $15, T2: $50 ~ Specialist visit no charge ü $150 $75 for 1/$75 ~ Prescriptions Generic drugs no charge ü $20 T1 & 2: $20 Preferred brand name drugs no charge ü $80 T1 & 2: $45 ü Non-preferred brand name drugs no charge ü $150 T1 & 2: $75 ü Specialty drugs no charge ü 20% ü T1 & 2: 40% ü Emergency Room (ER) visit no charge ü 20% ü $250 for 2/$250 ~ Inpatient hospital stay no charge ü 20% ü T1: $250, T2: $500 ü Option 1 Option 2 Option 3 Insurance company Consumers’ Choice Consumers’ Choice Coventry Health plan name Bronze HDP 1 Bronze 10 Bronze $15 Copay Upstate Plan type (HMO, PPO, POS, EPO, or other) EPO EPO POS Monthly premium (after tax credit) $0 $13 $56 Deductible (in-network/out-of-network) $11,000 $12,600 T1: $10,000/T2: $12,500 OOP Maximum (in-network/out-of-network) $11,000 $13,200 $13,200 Other Considerations Other Consideration: Other Consideration: Other Consideration: Scenario 2: the Green Family (family of 5)
88 Copays/Coinsurance Amount Amount Amount Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes) Primary Care Provider (PCP) visit no charge ü $40 T1: $15, T2: $50 ~ Specialist visit no charge ü $150 $75 for 1/$75 ~ Prescriptions Generic drugs no charge ü $20 T1 & 2: $20 Preferred brand name drugs no charge ü $80 T1 & 2: $45 ü Non-preferred brand name drugs no charge ü $150 T1 & 2: $75 ü Specialty drugs no charge ü 20% ü T1 & 2: 40% ü Emergency Room (ER) visit no charge ü 20% ü $250 for 2/$250 ~ Inpatient hospital stay no charge ü 20% ü T1: $250, T2: $500 ü Option 1 Option 2 Option 3 Insurance company Consumers’ Choice Consumers’ Choice Coventry Health plan name Bronze HDP 1 Bronze 10 Bronze $15 Copay Upstate Plan type (HMO, PPO, POS, EPO, or other) EPO EPO POS Monthly premium (after tax credit) $0 $13 $56 Deductible (in-network/out-of-network) $11,000 $12,600 T1: $10,000/T2: $12,500 OOP Maximum (in-network/out-of-network) $11,000 $13,200 $13,200 Other Considerations Other Consideration: out-of-network coverage? û û ü Other Consideration: Other Consideration: Scenario 2: the Green Family (family of 5)
89 Copays/Coinsurance Amount Amount Amount Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes) Primary Care Provider (PCP) visit no charge ü $40 T1: $15, T2: $50 ~ Specialist visit no charge ü $150 $75 for 1/$75 ~ Prescriptions Generic drugs no charge ü $20 T1 & 2: $20 Preferred brand name drugs no charge ü $80 T1 & 2: $45 ü Non-preferred brand name drugs no charge ü $150 T1 & 2: $75 ü Specialty drugs no charge ü 20% ü T1 & 2: 40% ü Emergency Room (ER) visit no charge ü 20% ü $250 for 2/$250 ~ Inpatient hospital stay no charge ü 20% ü T1: $250, T2: $500 ü Option 1 Option 2 Option 3 Insurance company Consumers’ Choice Consumers’ Choice Coventry Health plan name Bronze HDP 1 Bronze 10 Bronze $15 Copay Upstate Plan type (HMO, PPO, POS, EPO, or other) EPO EPO POS Monthly premium (after tax credit) $0 $13 $56 Deductible (in-network/out-of-network) $11,000 $12,600 T1: $10,000/T2: $12,500 OOP Maximum (in-network/out-of-network) $11,000 $13,200 $13,200 Other Considerations Other Consideration: out-of-network coverage? û û ü Other Consideration: Spanish speaking PCPs Other Consideration: Scenario 2: the Green Family (family of 5)
Scenario 2: the Green Family (family of 5) 90
Scenario 2: the Green Family (family of 5) 91
Scenario 2: the Green Family (family of 5) 92
Scenario 2: the Green Family (family of 5) 93
94 Copays/Coinsurance Amount Amount Amount Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes) Primary Care Provider (PCP) visit no charge ü $40 T1: $15, T2: $50 ~ Specialist visit no charge ü $150 $75 for 1/$75 ~ Prescriptions Generic drugs no charge ü $20 T1 & 2: $20 Preferred brand name drugs no charge ü $80 T1 & 2: $45 ü Non-preferred brand name drugs no charge ü $150 T1 & 2: $75 ü Specialty drugs no charge ü 20% ü T1 & 2: 40% ü Emergency Room (ER) visit no charge ü 20% ü $250 for 2/$250 ~ Inpatient hospital stay no charge ü 20% ü T1: $250, T2: $500 ü Option 1 Option 2 Option 3 Insurance company Consumers’ Choice Consumers’ Choice Coventry Health plan name Bronze HDP 1 Bronze 10 Bronze $15 Copay Upstate Plan type (HMO, PPO, POS, EPO, or other) EPO EPO POS Monthly premium (after tax credit) $0 $13 $56 Deductible (in-network/out-of-network) $11,000 $12,600 T1: $10,000/T2: $12,500 OOP Maximum (in-network/out-of-network) $11,000 $13,200 $13,200 Other Considerations Other Consideration: out-of-network coverage? û û ü Other Consideration: Spanish speaking PCPs Other Consideration: Scenario 2: the Green Family (family of 5)
95 Copays/Coinsurance Amount Amount Amount Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes) Primary Care Provider (PCP) visit no charge ü $40 T1: $15, T2: $50 ~ Specialist visit no charge ü $150 $75 for 1/$75 ~ Prescriptions Generic drugs no charge ü $20 T1 & 2: $20 Preferred brand name drugs no charge ü $80 T1 & 2: $45 ü Non-preferred brand name drugs no charge ü $150 T1 & 2: $75 ü Specialty drugs no charge ü 20% ü T1 & 2: 40% ü Emergency Room (ER) visit no charge ü 20% ü $250 for 2/$250 ~ Inpatient hospital stay no charge ü 20% ü T1: $250, T2: $500 ü Option 1 Option 2 Option 3 Insurance company Consumers’ Choice Consumers’ Choice Coventry Health plan name Bronze HDP 1 Bronze 10 Bronze $15 Copay Upstate Plan type (HMO, PPO, POS, EPO, or other) EPO EPO POS Monthly premium (after tax credit) $0 $13 $56 Deductible (in-network/out-of-network) $11,000 $12,600 T1: $10,000/T2: $12,500 OOP Maximum (in-network/out-of-network) $11,000 $13,200 $13,200 Other Considerations Other Consideration: out-of-network coverage? û û ü Other Consideration: Spanish speaking PCPs 19 (10 mi.) 26 (20 mi.) 19 (10 mi.) 26 (20 mi.) T1: 46, T2: 15 (10 mi.) Other Consideration: Scenario 2: the Green Family (family of 5)
Scenario 2: the Green Family (family of 5) 96
Scenario 2: the Green Family (family of 5) 97
98 Copays/Coinsurance Amount Amount Amount Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes) Primary Care Provider (PCP) visit no charge ü $40 T1: $15, T2: $50 ~ Specialist visit no charge ü $150 $75 for 1/$75 ~ Prescriptions Generic drugs no charge ü $20 T1 & 2: $20 Preferred brand name drugs no charge ü $80 T1 & 2: $45 ü Non-preferred brand name drugs no charge ü $150 T1 & 2: $75 ü Specialty drugs no charge ü 20% ü T1 & 2: 40% ü Emergency Room (ER) visit no charge ü 20% ü $250 for 2/$250 ~ Inpatient hospital stay no charge ü 20% ü T1: $250, T2: $500 ü Option 1 Option 2 Option 3 Insurance company Consumers’ Choice Consumers’ Choice Coventry Health plan name Bronze HDP 1 Bronze 10 Bronze $15 Copay Upstate Plan type (HMO, PPO, POS, EPO, or other) EPO EPO POS Monthly premium (after tax credit) $0 $13 $56 Deductible (in-network/out-of-network) $11,000 $12,600 T1: $10,000/T2: $12,500 OOP Maximum (in-network/out-of-network) $11,000 $13,200 $13,200 Other Considerations Other Consideration: out-of-network coverage? û û ü Other Consideration: Spanish speaking PCPs 19 (10 mi.) 26 (20 mi.) 19 (10 mi.) 26 (20 mi.) T1: 46, T2: 15 (10 mi.) Scenario 2: the Green Family (family of 5)
99 Copays/Coinsurance Amount Amount Amount Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes) Primary Care Provider (PCP) visit no charge ü $40 Specialist visit no charge ü $150 Prescriptions Generic drugs no charge ü $20 Preferred brand name drugs no charge ü $80 Non-preferred brand name drugs no charge ü $150 Specialty drugs no charge ü 20% ü Emergency Room (ER) visit no charge ü 20% ü Inpatient hospital stay no charge ü 20% ü Option 1 Option 2 Option 3 Insurance company Consumers’ Choice Consumers’ Choice Health plan name Bronze HDP 1 Bronze 10 Plan type (HMO, PPO, POS, EPO, or other) EPO EPO Monthly premium (after tax credit) $0 $13 Deductible (in-network/out-of-network) $11,000 $12,600 OOP Maximum (in-network/out-of-network) $11,000 $13,200 Other Considerations Other Consideration: out-of-network coverage? û û Other Consideration: Spanish speaking PCPs 19 (10 mi.) 26 (20 mi.) 19 (10 mi.) 26 (20 mi.) Scenario 2: the Green Family (family of 5)
10 0 Copays/Coinsurance Amount Amount Amount Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes) Primary Care Provider (PCP) visit no charge ü $40 $10 Specialist visit no charge ü $150 20% ü Prescriptions Generic drugs no charge ü $20 $10 Preferred brand name drugs no charge ü $80 20% ü Non-preferred brand name drugs no charge ü $150 20% ü Specialty drugs no charge ü 20% ü 20% ü Emergency Room (ER) visit no charge ü 20% ü 20% ü Inpatient hospital stay no charge ü 20% ü 20% ü Option 1 Option 2 Option 3 Insurance company Consumers’ Choice Consumers’ Choice Consumers’ Choice Health plan name Bronze HDP 1 Bronze 10 Silver 10 Plan type (HMO, PPO, POS, EPO, or other) EPO EPO EPO Monthly premium (after tax credit) $0 $13 $167 Deductible (in-network/out-of-network) $11,000 $12,600 $1,000 OOP Maximum (in-network/out-of-network) $11,000 $13,200 $3,000 Other Considerations Other Consideration: out-of-network coverage? û û û Other Consideration: Spanish speaking PCPs 19 (10 mi.) 26 (20 mi.) 19 (10 mi.) 26 (20 mi.) 19 (10 mi.) 26 (20 mi.) Scenario 2: the Green Family (family of 5)
10 1 Copays/Coinsurance Amount Amount Deductible applies? (check if yes) Deductible applies? (check if yes) Primary Care Provider (PCP) visit no charge ü $10 Specialist visit no charge ü 20% ü Prescriptions Generic drugs no charge ü $10 Preferred brand name drugs no charge ü 20% ü Non-preferred brand name drugs no charge ü 20% ü Specialty drugs no charge ü 20% ü Emergency Room (ER) visit no charge ü 20% ü Inpatient hospital stay no charge ü 20% ü Option 1 Option 3 Insurance company Consumers’ Choice Consumers’ Choice Health plan name Bronze HDP 1 Silver 10 Plan type (HMO, PPO, POS, EPO, or other) EPO EPO Monthly premium (after tax credit) $0 $167 Deductible (in-network/out-of-network) $11,000 $1,000 OOP Maximum (in-network/out-of-network) $11,000 $3,000 Other Considerations Other Consideration: out-of-network coverage? û û Other Consideration: Spanish speaking PCPs 19 (10 mi.) 26 (20 mi.) 19 (10 mi.) 26 (20 mi.) Scenario 2: the Green Family (family of 5) $0 $2,004 Annual Cost Annual Cost $6,400 $6,400 $40 $480 $4,124 $600 Health care needs: •  PCP checkup every 3 months ($120/visit) •  Four generic prescriptions per month ($40 retail) •  Hospitalization ($4,000 bill) $1,000
Identify the Green Family’s Priorities for Insurance •  Cheapest monthly payment? •  Manageable deductible? •  Low copays/coinsurance? •  Having “first dollar” coverage? (i.e. some services exempt from the deductible?) •  Current doctor in network? •  Size of network •  Prescription drugs covered? •  Out-of-network coverage? •  Language spoken by providers? •  Lowest overall annual cost (premiums + anticipated cost-sharing) 10 2
Interactive Exercise Assisting Consumers in Plan Selection
Assisting Consumers in Plan Selection 10 4
Scenario 1: Sasha (Tampa Bay Lightning Fan) 10 5 Sasha   Age   37   County   Hillsborough  County,  FL   Zip  Code   33601   Income   $25,000   Federal  Poverty  Level   212%   Employer  coverage?   no   APTC   $139.62/month   Cost-­‐sharing  ReducCons?   Yes  (Silver  73%)   Priorities •  Very concerned about cost •  Doesn’t have a specific doctor •  Has one prescription medication (generic)
B1   B2   B3   B4   QHPs available to Sasha (Tampa, FL) - Bronze 10 6
QHPs available to Sasha (Tampa, FL) - Bronze 10 7 B5   B6   B7  
S1   S2   S3   S4   QHPs available to Sasha (Tampa, FL) - Silver 10 8
S5   S5   S7   QHPs available to Sasha (Tampa, FL) - Silver 10 9
Scenario 2: Jillian and Michael (Chicago fans) 11 0 Jillian   Michael   Age   55   55   County   Cook  County,  IL   Zip  Code   60609   Income   $22,800   $7,200   Federal  Poverty  Level   188%   Employer  coverage?   no   no   APTC   $603.77/month   Cost-­‐sharing  ReducCons?   Yes  (Silver  87%)  
Scenario 2: Jillian and Michael (Chicago fans) 11 1
Contact Info Dave Chandra Senior Policy Analyst 202-408-1080 chandra@cbpp.org For more information and resources, please visit: www.healthreformbeyondthebasics.org a  project  of  the  Center  on  Budget  and  Policy  PrioriRes,  www.cbpp.org     11 2
113 New Training Resources •  Highly customized, Action-oriented •  New suite of training services •  Goal-setting •  Planning •  Coaching •  In-person training •  FOR MORE INFO – training@enrollamerica.org

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How to Efficiently and Effectively Help Consumers Navigate Plan Selection

  • 1.
    © 2015 EnrollAmerica and Get Covered America EnrollAmerica.org | GetCoveredAmerica.org Dave Chandra, Senior Policy Analyst, Center on Budget and Policy Priorities | 06.11.15 How to Effectively and Efficiently Help Consumers Navigate Plan Selection
  • 2.
    1.  Trends inMarketplace QHPs 2.  Analyzing QHPs in your Region 3.  Assisting Consumers in Plan Selection - Demonstration 4.  Assisting Consumers in Plan Selection - Interactive exercise 2 Presentation Overview
  • 3.
  • 4.
    Overview of MarketplaceHealth Plan Elements 1.  Premium 2.  Cost Sharing – Deductible – Co-pays/Co-insurance – Out-of-Pocket Maximum 3.  Benefits/Drug Formulary 4.  Provider Network 4
  • 5.
    Copays   Fixed  dollar  amount  per  visit  or  per  day   paid  by  the  enrollee.   Coinsurance   Percent  of  a  medical  fee/bill  paid  by  the   enrollee   Copays and Coinsurance Overview Source:  HealthCare.gov,  Kaiser  Permanente  KP  VA  0/20/Dental  and  KP  VA   1000/20/Dental  Gold  Plans  for  Fairfax  County,  VA   5
  • 6.
    Increase of Coinsurancein QHPs 6 Source:  HealthCare.gov,  Highmark  Health  Savings  Blue  PPO  2750  Silver  plan  for  Westmoreland  County,  PA  
  • 7.
    Copays and Coinsurance PrescriptionDrug Copay Tiers 7 Source:  HealthCare.gov,  UPMC  Advantage  Value  Silver  Select  plan  for  Westmoreland  County,  PA  
  • 8.
    Additional Tiering ofPrescription Drug Copays 8 Source:  Summary  of  Benefits  and  Coverage  for  Humana  Silver  4600/AusRn   HMOx  in  Travis  County,  TX  
  • 9.
    Additional Tiering ofPrescription Drug Copays 9 SourceHumana  Silver  4600/AusRn  HMOx  in  Travis  County,  TX  
  • 10.
    Services/Copays Exempt fromthe Deductible 10 Source:  HealthCare.gov,  Anthem  HealthKeepers  Silver  X  3350  15  plan  for  Fairfax  County,  VA   deduc%ble   applies  
  • 11.
    Services/Copays Exempt fromthe Deductible 11 Source:  HealthCare.gov,  Anthem  HealthKeepers  Silver  X  3350  15  plan  for  Fairfax  County,  VA   deduc%ble   does  not   apply  
  • 12.
    HSA vs. Non-HSAPlans 12 Source:  HealthCare.gov,  Kaiser  Permanente  Bronze  4500/5-­‐/HAS/Dental/Ped   Dental  and  Bronze  4500/5-­‐/Dental/Ped  Dental    plans  in  Fairfax  County  VA  
  • 13.
    “3 Step Copay”(Copay/Deductible/Coinsurance) 13 Source:  Summary  of  Benefits  and  Coverage  for  Anthem  HealthKeepers  Bronze  X   4500  35  in  Fairfax  County,  VA  
  • 14.
    “3 Step Copay”(Copay/Deductible/Coinsurance) 14 Source:  HealthCare.gov,  Anthem  HealthKeepers  Bronze  X  4500  35  in  Fairfax   County,  VA  
  • 15.
    Cost Sharing Reduction(CSR) Plans 15 FPL%   Silver  Plan  Eligibility   <  150%   94%  variant   151%  -­‐  200%   87%  variant   201%  -­‐  250%   73%  variant   >  251%   70%  base  plan  
  • 16.
    Cost Sharing Reduction(CSR) Plans 16
  • 17.
    Cost Sharing Reduction(CSR) Plans 17
  • 18.
  • 19.
    Pediatric Dental Benefit Source:  healthcare.gov,  InnovaRon  Health-­‐Aetna  INOVA  Silver  $10  Copay  plan  and   Kaiser  Permanente  VA  Silver  1750/25%/HSA/Dental/Ped  Dental  plan  for  Fairfax   County,  VA   19
  • 20.
    Essential Health Benefits OtherCovered Services 20 Source:  Summary  of  Benefits  and  Coverage  for  New  Mexico  Health  ConnecRons   Healthy  Connect  Bronze  HMO  in  Albuquerque,  NM  
  • 21.
    21 Type   Name   PCP   Required?   Referrals   Required?   Out-­‐of-­‐ Network   Coverage?   PPO   Preferred  Provider  Organiza%on   No   No   Yes   POS   Point  of  Service   Yes   Maybe   Yes   HMO   Health  Maintenance  Organiza%on   Yes   Yes   No*   EPO   Exclusive  Provider  Organiza%on   No   No   No*   *except  for  emergency  care   Health Plan Network Types
  • 22.
    QHPs with NarrowProvider Networks Health plans are using narrow provider networks to keep costs down 22
  • 23.
    QHPs with TieredNetworks 23 Source:  Plan  Brochure  for  Independence  Blue  Cross  HMO  Silver  ProacRve  Plan   in  Philadelphia  County,  PA  
  • 24.
    Tiered Provider Networks 24 Source:  Summary  of  Benefits  and  Coverage  for  Independence  Blue  Cross  HMO   Silver  ProacRve  Plan  in  Philadelphia  County,  PA  
  • 25.
    Confusion and Inaccuraciesin Provider Directories 25 Source:  HealthCare.gov  and  Provider  Search  site  for  BlueCross  BlueShield  BlueCare  SoluRons  Plan  in  Sedgwick  County,   KS    
  • 26.
    Preparing for OpenEnrollment III Analyzing QHPs in your Region
  • 27.
    Comparing 2014 and2015 Marketplace Plans 27 Source:  ProPublica,    h`p://projects.propublica.org/aca-­‐enrollment/#    
  • 28.
    Comparing 2014 and2015 Marketplace Plans 28 Source:  ProPublica,    h`p://projects.propublica.org/aca-­‐enrollment/#    
  • 29.
    Analyzing Changes toQHPs in Your Region 29
  • 30.
    Comparing QHPs inYour Region 30
  • 31.
    Comparing QHPs inYour Region – Additional Benefits 31 Service   CareFirst  BCBS   Innova%on   Health   Kaiser   Permanente   Acupuncture   Bariatric  Surgery   X   X   ChiropracCc  Care     X   X   X   CosmeCc  Surgery   Coverage  Outside  the  U.S.   X   Dental  Care  for  Adults   X   Dental  Care  for  Children   X   Hearing  Aids   Hearing  Aids   InferClity  Treatment     X   Long-­‐Term/Custodial   Nursing  Home  Care   Non-­‐Emergency  Care  when   Traveling  Outside  the  US   X   Private-­‐Duty  Nursing     X   X   X   Eye  Care  for  Adults   X   X   RouCne  Foot  Care   RouCne  Hearing  Tests   X   Weight  Loss  Programs  
  • 32.
  • 33.
    CBPP Marketplace PlanComparison Worksheet available  at:     hQp:// www.healthreformbeyondthebasics.org/ marketplace-­‐plan-­‐comparison-­‐worksheet/     33
  • 34.
    Scenario 1: Jamesand Ann (married couple) 34 James   Ann   Age   52   45   County   Oakland  County,  MI   Zip  Code   48324   Income   $0   $23,000   Federal  Poverty  Level   144%   Employer  coverage?   no   no   Insurance  status   uninsured   uninsured  
  • 35.
    Scenario 1: Jamesand Ann (married couple) 35
  • 36.
    Scenario 1: Jamesand Ann (married couple) 36
  • 37.
    Scenario 1: Jamesand Ann (married couple) 37
  • 38.
    Scenario 1: Jamesand Ann (married couple) 38 Applicant  Name:     Tax  Credit  (monthly):     Date:   Number  of  people  in  the  plan:       Eligible  for  cost-­‐sharing  reducCons?     □  No        □  73%        □  87%        □  94%           Marketplace  Plan  Comparison  Worksheet   Option 1 Option 2 Option 3 Insurance company Health plan name Metal tier (Bronze, Silver, Gold, Platinum) Plan type (HMO, PPO, POS, EPO, or other) Monthly premium (after tax credit)
  • 39.
    Scenario 1: Jamesand Ann (married couple) 39 Applicant  Name:        James and Ann Tax  Credit  (monthly):     $549.66     Date:   6/11/15   Number  of  people  in  the  plan:       2 Eligible  for  cost-­‐sharing  reducCons?     □  No        □  73%        □  87%        ý  94%           Marketplace  Plan  Comparison  Worksheet   Option 1 Option 2 Option 3 Insurance company Health plan name Metal tier (Bronze, Silver, Gold, Platinum) Plan type (HMO, PPO, POS, EPO, or other) Monthly premium (after tax credit)
  • 40.
    40 Copays/Coinsurance Amount AmountAmount Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes) Primary Care Provider (PCP) visit Specialist visit Prescriptions Generic drugs Preferred brand name drugs Non-preferred brand name drugs Specialty drugs Emergency Room (ER) visit Inpatient hospital stay Other service: Other service: Option 1 Option 2 Option 3 Insurance company Health plan name Plan type (HMO, PPO, POS, EPO, or other) Monthly premium (after tax credit) Deductible (medical/drug or combined) Out-of-Pocket Maximum (OOP Max) Health Care Providers In Network/Covered? In Network/Covered? In Network/Covered? Current doctor/provider: Other provider or hospital: Current prescription drugs: Scenario 1: James and Ann (married couple)
  • 41.
    41 Copays/Coinsurance Amount AmountAmount Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes) Primary Care Provider (PCP) visit Specialist visit Prescriptions Generic drugs Preferred brand name drugs Non-preferred brand name drugs Specialty drugs Emergency Room (ER) visit Inpatient hospital stay Other service: Laboratory Services Other service: X-rays and Diagnostic Imaging Option 1 Option 2 Option 3 Insurance company Health plan name Plan type (HMO, PPO, POS, EPO, or other) Monthly premium (after tax credit) Deductible (medical/drug or combined) Out-of-Pocket Maximum (OOP Max) Health Care Providers In Network/Covered? In Network/Covered? In Network/Covered? Current doctor/provider: Other provider or hospital: Current prescription drugs: Scenario 1: James and Ann (married couple)
  • 42.
    Scenario 1: Jamesand Ann (married couple)
  • 43.
    Scenario 1: Jamesand Ann (married couple)
  • 44.
    44 Scenario 1: Jamesand Ann (married couple)
  • 45.
    45 Scenario 1: Jamesand Ann (married couple)
  • 46.
    46 Scenario 1: Jamesand Ann (married couple)
  • 47.
    47 Copays/Coinsurance Amount AmountAmount Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes) Primary Care Provider (PCP) visit Specialist visit Prescriptions Generic drugs Preferred brand name drugs Non-preferred brand name drugs Specialty drugs Emergency Room (ER) visit Inpatient hospital stay Other service: Laboratory Services Other service: X-rays and Diagnostic Imaging Option 1 Option 2 Option 3 Insurance company Health plan name Plan type (HMO, PPO, POS, EPO, or other) Monthly premium (after tax credit) Deductible (medical/drug or combined) Out-of-Pocket Maximum (OOP Max) Health Care Providers In Network/Covered? In Network/Covered? In Network/Covered? Current doctor/provider: Other provider or hospital: Current prescription drugs: Scenario 1: James and Ann (married couple)
  • 48.
    48 Copays/Coinsurance Amount AmountAmount Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes) Primary Care Provider (PCP) visit Specialist visit Prescriptions Generic drugs Preferred brand name drugs Non-preferred brand name drugs Specialty drugs Emergency Room (ER) visit Inpatient hospital stay Other service: Laboratory Services Other service: X-rays and Diagnostic Imaging Option 1 Option 2 Option 3 Insurance company Humana Health plan name Silver 4600/Detroit HMOx Plan type (HMO, PPO, POS, EPO, or other) HMO Monthly premium (after tax credit) $36 Deductible (medical/drug or combined) $1,000 (combined) Out-of-Pocket Maximum (OOP Max) $1,500 Health Care Providers In Network/Covered? In Network/Covered? In Network/Covered? Current doctor/provider: Other provider or hospital: Current prescription drugs: Scenario 1: James and Ann (married couple)
  • 49.
    49 Copays/Coinsurance Amount AmountAmount Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes) Primary Care Provider (PCP) visit $25 Specialist visit $35 Prescriptions Generic drugs $17* Preferred brand name drugs $50 ü Non-preferred brand name drugs 50% ü Specialty drugs 50% ü Emergency Room (ER) visit 20% ü Inpatient hospital stay 20% ü Other service: Laboratory Services 20% ü Other service: X-rays and Diagnostic Imaging 20% ü Option 1 Option 2 Option 3 Insurance company Humana Health plan name Silver 4600/Detroit HMOx Plan type (HMO, PPO, POS, EPO, or other) HMO Monthly premium (after tax credit) $36 Deductible (medical/drug or combined) $1,000 (combined) Out-of-Pocket Maximum (OOP Max) $1,500 Health Care Providers In Network/Covered? In Network/Covered? In Network/Covered? Current doctor/provider: Other provider or hospital: Current prescription drugs: Scenario 1: James and Ann (married couple)
  • 50.
    50 Copays/Coinsurance Amount AmountAmount Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes) Primary Care Provider (PCP) visit $25 $10 Specialist visit $35 $30 ü Prescriptions Generic drugs $17* 1A - $4, 1B - $20 Preferred brand name drugs $50 ü 25% ü Non-preferred brand name drugs 50% ü 50% ü Specialty drugs 50% ü 20% ü Emergency Room (ER) visit 20% ü $100/10% ü Inpatient hospital stay 20% ü 10% ü Other service: Laboratory Services 20% ü no charge ü Other service: X-rays and Diagnostic Imaging 20% ü 10% ü Option 1 Option 2 Option 3 Insurance company Humana Blue Care Network of MI Health plan name Silver 4600/Detroit HMOx Metro Detroit HMO Silver Plan type (HMO, PPO, POS, EPO, or other) HMO HMO Monthly premium (after tax credit) $36 $73 Deductible (medical/drug or combined) $1,000 (combined) $350 (combined) Out-of-Pocket Maximum (OOP Max) $1,500 $1,000 Health Care Providers In Network/Covered? In Network/Covered? In Network/Covered? Current doctor/provider: Other provider or hospital: Current prescription drugs: Scenario 1: James and Ann (married couple)
  • 51.
    51 Copays/Coinsurance Amount AmountAmount Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes) Primary Care Provider (PCP) visit $25 $10 $10 n/a Specialist visit $35 $30 ü $20 n/a Prescriptions Generic drugs $17* 1A - $4, 1B - $20 no charge n/a Preferred brand name drugs $50 ü 25% ü $15 n/a Non-preferred brand name drugs 50% ü 50% ü $50 n/a Specialty drugs 50% ü 20% ü $50 n/a Emergency Room (ER) visit 20% ü $100/10% ü $75 n/a Inpatient hospital stay 20% ü 10% ü no charge n/a Other service: Laboratory Services 20% ü no charge ü no charge n/a Other service: X-rays and Diagnostic Imaging 20% ü 10% ü $20 n/a Option 1 Option 2 Option 3 Insurance company Humana Blue Care Network of MI Total Health Care USA Health plan name Silver 4600/Detroit HMOx Metro Detroit HMO Silver Totally You (Silver) Plan type (HMO, PPO, POS, EPO, or other) HMO HMO HMO Monthly premium (after tax credit) $36 $73 $96 Deductible (medical/drug or combined) $1,000 (combined) $350 (combined) $0 Out-of-Pocket Maximum (OOP Max) $1,500 $1,000 $1,500 Health Care Providers In Network/Covered? In Network/Covered? In Network/Covered? Current doctor/provider: Other provider or hospital: Current prescription drugs: Scenario 1: James and Ann (married couple)
  • 52.
    52 Copays/Coinsurance Amount AmountAmount Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes) Primary Care Provider (PCP) visit $25 $10 $10 n/a Specialist visit $35 $30 ü $20 n/a Prescriptions Generic drugs $17* 1A - $4, 1B - $20 no charge n/a Preferred brand name drugs $50 ü 25% ü $15 n/a Non-preferred brand name drugs 50% ü 50% ü $50 n/a Specialty drugs 50% ü 20% ü $50 n/a Emergency Room (ER) visit 20% ü $100/10% ü $75 n/a Inpatient hospital stay 20% ü 10% ü no charge n/a Other service: Laboratory Services 20% ü no charge ü no charge n/a Other service: X-rays and Diagnostic Imaging 20% ü 10% ü $20 n/a Option 1 Option 2 Option 3 Insurance company Humana Blue Care Network of MI Total Health Care USA Health plan name Silver 4600/Detroit HMOx Metro Detroit HMO Silver Totally You (Silver) Plan type (HMO, PPO, POS, EPO, or other) HMO HMO HMO Monthly premium (after tax credit) $36 $73 $96 Deductible (medical/drug or combined) $1,000 (combined) $350 (combined) $0 Out-of-Pocket Maximum (OOP Max) $1,500 $1,000 $1,500 Health Care Providers In Network/Covered? In Network/Covered? In Network/Covered? Current doctor/provider: D. Willens, MD Other provider or hospital: Current prescription drugs: Scenario 1: James and Ann (married couple)
  • 53.
    53 Copays/Coinsurance Amount AmountAmount Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes) Primary Care Provider (PCP) visit $25 $10 $10 n/a Specialist visit $35 $30 ü $20 n/a Prescriptions Generic drugs $17* 1A - $4, 1B - $20 no charge n/a Preferred brand name drugs $50 ü 25% ü $15 n/a Non-preferred brand name drugs 50% ü 50% ü $50 n/a Specialty drugs 50% ü 20% ü $50 n/a Emergency Room (ER) visit 20% ü $100/10% ü $75 n/a Inpatient hospital stay 20% ü 10% ü no charge n/a Other service: Laboratory Services 20% ü no charge ü no charge n/a Other service: X-rays and Diagnostic Imaging 20% ü 10% ü $20 n/a Option 1 Option 2 Option 3 Insurance company Humana Blue Care Network of MI Total Health Care USA Health plan name Silver 4600/Detroit HMOx Metro Detroit HMO Silver Totally You (Silver) Plan type (HMO, PPO, POS, EPO, or other) HMO HMO HMO Monthly premium (after tax credit) $36 $73 $96 Deductible (medical/drug or combined) $1,000 (combined) $350 (combined) $0 Out-of-Pocket Maximum (OOP Max) $1,500 $1,000 $1,500 Health Care Providers In Network/Covered? In Network/Covered? In Network/Covered? Current doctor/provider: D. Willens, MD Other provider or hospital: # of oncologists Current prescription drugs: Scenario 1: James and Ann (married couple)
  • 54.
    54 Copays/Coinsurance Amount AmountAmount Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes) Primary Care Provider (PCP) visit $25 $10 $10 n/a Specialist visit $35 $30 ü $20 n/a Prescriptions Generic drugs $17* 1A - $4, 1B - $20 no charge n/a Preferred brand name drugs $50 ü 25% ü $15 n/a Non-preferred brand name drugs 50% ü 50% ü $50 n/a Specialty drugs 50% ü 20% ü $50 n/a Emergency Room (ER) visit 20% ü $100/10% ü $75 n/a Inpatient hospital stay 20% ü 10% ü no charge n/a Other service: Laboratory Services 20% ü no charge ü no charge n/a Other service: X-rays and Diagnostic Imaging 20% ü 10% ü $20 n/a Option 1 Option 2 Option 3 Insurance company Humana Blue Care Network of MI Total Health Care USA Health plan name Silver 4600/Detroit HMOx Metro Detroit HMO Silver Totally You (Silver) Plan type (HMO, PPO, POS, EPO, or other) HMO HMO HMO Monthly premium (after tax credit) $36 $73 $96 Deductible (medical/drug or combined) $1,000 (combined) $350 (combined) $0 Out-of-Pocket Maximum (OOP Max) $1,500 $1,000 $1,500 Health Care Providers In Network/Covered? In Network/Covered? In Network/Covered? Current doctor/provider: D. Willens, MD Other provider or hospital: # of oncologists Current prescription drugs: metformin Scenario 1: James and Ann (married couple)
  • 55.
    55 Scenario 1: Jamesand Ann (married couple)
  • 56.
    56 Scenario 1: Jamesand Ann (married couple)
  • 57.
    57 Scenario 1: Jamesand Ann (married couple)
  • 58.
    58 Scenario 1: Jamesand Ann (married couple)
  • 59.
    59 Scenario 1: Jamesand Ann (married couple)
  • 60.
    60 Scenario 1: Jamesand Ann (married couple)
  • 61.
    61 Scenario 1: Jamesand Ann (married couple)
  • 62.
    62 Copays/Coinsurance Amount AmountAmount Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes) Primary Care Provider (PCP) visit $25 $10 $10 n/a Specialist visit $35 $30 ü $20 n/a Prescriptions Generic drugs $17* 1A - $4, 1B - $20 no charge n/a Preferred brand name drugs $50 ü 25% ü $15 n/a Non-preferred brand name drugs 50% ü 50% ü $50 n/a Specialty drugs 50% ü 20% ü $50 n/a Emergency Room (ER) visit 20% ü $100/10% ü $75 n/a Inpatient hospital stay 20% ü 10% ü no charge n/a Other service: Laboratory Services 20% ü no charge ü no charge n/a Other service: X-rays and Diagnostic Imaging 20% ü 10% ü $20 n/a Option 1 Option 2 Option 3 Insurance company Humana Blue Care Network of MI Total Health Care USA Health plan name Silver 4600/Detroit HMOx Metro Detroit HMO Silver Totally You (Silver) Plan type (HMO, PPO, POS, EPO, or other) HMO HMO HMO Monthly premium (after tax credit) $36 $73 $96 Deductible (medical/drug or combined) $1,000 (combined) $350 (combined) $0 Out-of-Pocket Maximum (OOP Max) $1,500 $1,000 $1,500 Health Care Providers In Network/Covered? In Network/Covered? In Network/Covered? Current doctor/provider: D. Willens, MD Other provider or hospital: # of oncologists Current prescription drugs: metformin Scenario 1: James and Ann (married couple)
  • 63.
    63 Copays/Coinsurance Amount AmountAmount Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes) Primary Care Provider (PCP) visit $25 $10 $10 n/a Specialist visit $35 $30 ü $20 n/a Prescriptions Generic drugs $17* 1A - $4, 1B - $20 no charge n/a Preferred brand name drugs $50 ü 25% ü $15 n/a Non-preferred brand name drugs 50% ü 50% ü $50 n/a Specialty drugs 50% ü 20% ü $50 n/a Emergency Room (ER) visit 20% ü $100/10% ü $75 n/a Inpatient hospital stay 20% ü 10% ü no charge n/a Other service: Laboratory Services 20% ü no charge ü no charge n/a Other service: X-rays and Diagnostic Imaging 20% ü 10% ü $20 n/a Option 1 Option 2 Option 3 Insurance company Humana Blue Care Network of MI Total Health Care USA Health plan name Silver 4600/Detroit HMOx Metro Detroit HMO Silver Totally You (Silver) Plan type (HMO, PPO, POS, EPO, or other) HMO HMO HMO Monthly premium (after tax credit) $36 $73 $96 Deductible (medical/drug or combined) $1,000 (combined) $350 (combined) $0 Out-of-Pocket Maximum (OOP Max) $1,500 $1,000 $1,500 Health Care Providers In Network/Covered? In Network/Covered? In Network/Covered? Current doctor/provider: D. Willens, MD û û û Other provider or hospital: # of oncologists Current prescription drugs: metformin Scenario 1: James and Ann (married couple)
  • 64.
    64 Scenario 1: Jamesand Ann (married couple)
  • 65.
    65 Scenario 1: Jamesand Ann (married couple)
  • 66.
    66 Copays/Coinsurance Amount AmountAmount Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes) Primary Care Provider (PCP) visit $25 $10 $10 n/a Specialist visit $35 $30 ü $20 n/a Prescriptions Generic drugs $17* 1A - $4, 1B - $10 no charge n/a Preferred brand name drugs $50 ü 25% ü $15 n/a Non-preferred brand name drugs 50% ü 50% ü $50 n/a Specialty drugs 50% ü 20% ü $50 n/a Emergency Room (ER) visit 20% ü $100/10% ü $75 n/a Inpatient hospital stay 20% ü 10% ü no charge n/a Other service: Laboratory Services 20% ü no charge ü no charge n/a Other service: X-rays and Diagnostic Imaging 20% ü 10% ü $20 n/a Option 1 Option 2 Option 3 Insurance company Humana Blue Care Network of MI Total Health Care USA Health plan name Silver 4600/Detroit HMOx Metro Detroit HMO Silver Totally You (Silver) Plan type (HMO, PPO, POS, EPO, or other) HMO HMO HMO Monthly premium (after tax credit) $36 $73 $96 Deductible (medical/drug or combined) $1,000 (combined) $350 (combined) $0 Out-of-Pocket Maximum (OOP Max) $1,500 $1,000 $1,500 Health Care Providers In Network/Covered? In Network/Covered? In Network/Covered? Current doctor/provider: D. Willens, MD û û û Other provider or hospital: # of oncologists Current prescription drugs: metformin Scenario 1: James and Ann (married couple)
  • 67.
    67 Copays/Coinsurance Amount AmountAmount Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes) Primary Care Provider (PCP) visit $25 $10 $10 n/a Specialist visit $35 $30 ü $20 n/a Prescriptions Generic drugs $17* 1A - $4, 1B - $20 no charge n/a Preferred brand name drugs $50 ü 25% ü $15 n/a Non-preferred brand name drugs 50% ü 50% ü $50 n/a Specialty drugs 50% ü 20% ü $50 n/a Emergency Room (ER) visit 20% ü $100/10% ü $75 n/a Inpatient hospital stay 20% ü 10% ü no charge n/a Other service: Laboratory Services 20% ü no charge ü no charge n/a Other service: X-rays and Diagnostic Imaging 20% ü 10% ü $20 n/a Option 1 Option 2 Option 3 Insurance company Humana Blue Care Network of MI Total Health Care USA Health plan name Silver 4600/Detroit HMOx Metro Detroit HMO Silver Totally You (Silver) Plan type (HMO, PPO, POS, EPO, or other) HMO HMO HMO Monthly premium (after tax credit) $36 $73 $96 Deductible (medical/drug or combined) $1,000 (combined) $350 (combined) $0 Out-of-Pocket Maximum (OOP Max) $1,500 $1,000 $1,500 Health Care Providers In Network/Covered? In Network/Covered? In Network/Covered? Current doctor/provider: D. Willens, MD û û û Other provider or hospital: # of oncologists 33 (10 mi.), 69 (20 mi.) 49 (10 mi.), 174 (25 mi.) 17 (10 mi.), 96 (25 mi.) Current prescription drugs: metformin Scenario 1: James and Ann (married couple)
  • 68.
    68 Scenario 1: Jamesand Ann (married couple)
  • 69.
    69 Scenario 1: Jamesand Ann (married couple)
  • 70.
    70 Scenario 1: Jamesand Ann (married couple)
  • 71.
    71 Scenario 1: Jamesand Ann (married couple)
  • 72.
    72 Scenario 1: Jamesand Ann (married couple)
  • 73.
    73 Copays/Coinsurance Amount AmountAmount Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes) Primary Care Provider (PCP) visit $25 $10 $10 n/a Specialist visit $35 $30 ü $20 n/a Prescriptions Generic drugs $17* 1A - $4, 1B - $20 no charge n/a Preferred brand name drugs $50 ü 25% ü $15 n/a Non-preferred brand name drugs 50% ü 50% ü $50 n/a Specialty drugs 50% ü 20% ü $50 n/a Emergency Room (ER) visit 20% ü $100/10% ü $75 n/a Inpatient hospital stay 20% ü 10% ü no charge n/a Other service: Laboratory Services 20% ü no charge ü no charge n/a Other service: X-rays and Diagnostic Imaging 20% ü 10% ü $20 n/a Option 1 Option 2 Option 3 Insurance company Humana Blue Care Network of MI Total Health Care USA Health plan name Silver 4600/Detroit HMOx Metro Detroit HMO Silver Totally You (Silver) Plan type (HMO, PPO, POS, EPO, or other) HMO HMO HMO Monthly premium (after tax credit) $36 $73 $96 Deductible (medical/drug or combined) $1,000 (combined) $350 (combined) $0 Out-of-Pocket Maximum (OOP Max) $1,500 $1,000 $1,500 Health Care Providers In Network/Covered? In Network/Covered? In Network/Covered? Current doctor/provider: D. Willens, MD û û û Other provider or hospital: # of oncologists 33 (10 mi.), 69 (20 mi.) 49 (10 mi.), 174 (25 mi.) 17 (10 mi.), 96 (25 mi.) Current prescription drugs: metformin Scenario 1: James and Ann (married couple)
  • 74.
    74 Copays/Coinsurance Amount AmountAmount Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes) Primary Care Provider (PCP) visit $25 $10 $10 n/a Specialist visit $35 $30 ü $20 n/a Prescriptions Generic drugs $17* 1A - $4, 1B - $20 no charge n/a Preferred brand name drugs $50 ü 25% ü $15 n/a Non-preferred brand name drugs 50% ü 50% ü $50 n/a Specialty drugs 50% ü 20% ü $50 n/a Emergency Room (ER) visit 20% ü $100/10% ü $75 n/a Inpatient hospital stay 20% ü 10% ü no charge n/a Other service: Laboratory Services 20% ü no charge ü no charge n/a Other service: X-rays and Diagnostic Imaging 20% ü 10% ü $20 n/a Option 1 Option 2 Option 3 Insurance company Humana Blue Care Network of MI Total Health Care USA Health plan name Silver 4600/Detroit HMOx Metro Detroit HMO Silver Totally You (Silver) Plan type (HMO, PPO, POS, EPO, or other) HMO HMO HMO Monthly premium (after tax credit) $36 $73 $96 Deductible (medical/drug or combined) $1,000 (combined) $350 (combined) $0 Out-of-Pocket Maximum (OOP Max) $1,500 $1,000 $1,500 Health Care Providers In Network/Covered? In Network/Covered? In Network/Covered? Current doctor/provider: D. Willens, MD û û û Other provider or hospital: # of oncologists 33 (10 mi.), 69 (20 mi.) 49 (10 mi.), 174 (25 mi.) 17 (10 mi.), 96 (25 mi.) Current prescription drugs: metformin yes (tier 1 & 2) yes (tier 1A) yes (tier 1 & 3) Scenario 1: James and Ann (married couple)
  • 75.
    •  Cheapest monthlypayment? •  Manageable deductible? •  Low copays/coinsurance? •  Having “first dollar” coverage? (i.e. some services exempt from the deductible)? •  Prescription drugs covered? •  Current doctor in network? •  Size of network? Identify James’s and Ann’s Priorities for Insurance 75
  • 76.
    76 *Jennifer  can  be  claimed  as  a  tax  dependent  as  a  qualifying  relaRve   because  she  is  receives  more  than  half  of  her  support  from  her   parents  and  makes  less  than  $3,950   Scenario 2: the Green Family (family of 5) Rosa   Dan   Jennifer*   Kristy   Cara   Age   43   43   20   16   10   County  (Zip  Code)   Greenville  County,  SC  (29607)   Income   $25,000   $20,000   $0   $0   $0   FPL   161  %FPL   Employer  coverage   no   no   no   no   no   Insurance  status   uninsured   uninsured   uninsured   on  Medicaid   on  Medicaid  
  • 77.
    77 Scenario 2: theGreen Family (family of 5)
  • 78.
    Scenario 2: theGreen Family (family of 5) 78 Applicant  Name:         Tax  Credit  (monthly):     Date:   Number  of  people  in  the  plan:       Eligible  for  cost-­‐sharing  reducCons?     □  No        □  73%        □  87%        □  94%           Marketplace  Plan  Comparison  Worksheet   Option 1 Option 2 Option 3 Insurance company Health plan name Metal tier (Bronze, Silver, Gold, Platinum) Plan type (HMO, PPO, POS, EPO, or other) Monthly premium (after tax credit)
  • 79.
    Scenario 2: theGreen Family (family of 5) 79 Applicant  Name:     Rosa, Dan, Jennifer Tax  Credit  (monthly):     $548.80   Date:   6/11/15   Number  of  people  in  the  plan:       3 Eligible  for  cost-­‐sharing  reducCons?     □  No        □  73%        ý  87%        □  94%           Marketplace  Plan  Comparison  Worksheet   Option 1 Option 2 Option 3 Insurance company Health plan name Metal tier (Bronze, Silver, Gold, Platinum) Plan type (HMO, PPO, POS, EPO, or other) Monthly premium (after tax credit)
  • 80.
    Scenario 2: theGreen Family (family of 5) 80
  • 81.
    Scenario 2: theGreen Family (family of 5) 81
  • 82.
    Scenario 2: theGreen Family (family of 5) 82
  • 83.
    Scenario 2: theGreen Family (family of 5) 83
  • 84.
    84 Copays/Coinsurance Amount AmountAmount Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes) Primary Care Provider (PCP) visit Specialist visit Prescriptions Generic drugs Preferred brand name drugs Non-preferred brand name drugs Specialty drugs Emergency Room (ER) visit Inpatient hospital stay Option 1 Option 2 Option 3 Insurance company Health plan name Plan type (HMO, PPO, POS, EPO, or other) Monthly premium (after tax credit) Deductible (in-network/out-of-network) OOP Maximum (in-network/out-of-network) Other Considerations Other Consideration: Other Consideration: Other Consideration: Scenario 2: the Green Family (family of 5)
  • 85.
    85 Copays/Coinsurance Amount AmountAmount Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes) Primary Care Provider (PCP) visit no charge ü Specialist visit no charge ü Prescriptions Generic drugs no charge ü Preferred brand name drugs no charge ü Non-preferred brand name drugs no charge ü Specialty drugs no charge ü Emergency Room (ER) visit no charge ü Inpatient hospital stay no charge ü Option 1 Option 2 Option 3 Insurance company Consumers’ Choice Health plan name Bronze HDP 1 Plan type (HMO, PPO, POS, EPO, or other) EPO Monthly premium (after tax credit) $0 Deductible (in-network/out-of-network) $11,000 OOP Maximum (in-network/out-of-network) $11,000 Other Considerations Other Consideration: Other Consideration: Other Consideration: Scenario 2: the Green Family (family of 5)
  • 86.
    86 Copays/Coinsurance Amount AmountAmount Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes) Primary Care Provider (PCP) visit no charge ü $40 Specialist visit no charge ü $150 Prescriptions Generic drugs no charge ü $20 Preferred brand name drugs no charge ü $80 Non-preferred brand name drugs no charge ü $150 Specialty drugs no charge ü 20% ü Emergency Room (ER) visit no charge ü 20% ü Inpatient hospital stay no charge ü 20% ü Option 1 Option 2 Option 3 Insurance company Consumers’ Choice Consumers’ Choice Health plan name Bronze HDP 1 Bronze 10 Plan type (HMO, PPO, POS, EPO, or other) EPO EPO Monthly premium (after tax credit) $0 $13 Deductible (in-network/out-of-network) $11,000 $12,600 OOP Maximum (in-network/out-of-network) $11,000 $13,200 Other Considerations Other Consideration: Other Consideration: Other Consideration: Scenario 2: the Green Family (family of 5)
  • 87.
    87 Copays/Coinsurance Amount AmountAmount Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes) Primary Care Provider (PCP) visit no charge ü $40 T1: $15, T2: $50 ~ Specialist visit no charge ü $150 $75 for 1/$75 ~ Prescriptions Generic drugs no charge ü $20 T1 & 2: $20 Preferred brand name drugs no charge ü $80 T1 & 2: $45 ü Non-preferred brand name drugs no charge ü $150 T1 & 2: $75 ü Specialty drugs no charge ü 20% ü T1 & 2: 40% ü Emergency Room (ER) visit no charge ü 20% ü $250 for 2/$250 ~ Inpatient hospital stay no charge ü 20% ü T1: $250, T2: $500 ü Option 1 Option 2 Option 3 Insurance company Consumers’ Choice Consumers’ Choice Coventry Health plan name Bronze HDP 1 Bronze 10 Bronze $15 Copay Upstate Plan type (HMO, PPO, POS, EPO, or other) EPO EPO POS Monthly premium (after tax credit) $0 $13 $56 Deductible (in-network/out-of-network) $11,000 $12,600 T1: $10,000/T2: $12,500 OOP Maximum (in-network/out-of-network) $11,000 $13,200 $13,200 Other Considerations Other Consideration: Other Consideration: Other Consideration: Scenario 2: the Green Family (family of 5)
  • 88.
    88 Copays/Coinsurance Amount AmountAmount Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes) Primary Care Provider (PCP) visit no charge ü $40 T1: $15, T2: $50 ~ Specialist visit no charge ü $150 $75 for 1/$75 ~ Prescriptions Generic drugs no charge ü $20 T1 & 2: $20 Preferred brand name drugs no charge ü $80 T1 & 2: $45 ü Non-preferred brand name drugs no charge ü $150 T1 & 2: $75 ü Specialty drugs no charge ü 20% ü T1 & 2: 40% ü Emergency Room (ER) visit no charge ü 20% ü $250 for 2/$250 ~ Inpatient hospital stay no charge ü 20% ü T1: $250, T2: $500 ü Option 1 Option 2 Option 3 Insurance company Consumers’ Choice Consumers’ Choice Coventry Health plan name Bronze HDP 1 Bronze 10 Bronze $15 Copay Upstate Plan type (HMO, PPO, POS, EPO, or other) EPO EPO POS Monthly premium (after tax credit) $0 $13 $56 Deductible (in-network/out-of-network) $11,000 $12,600 T1: $10,000/T2: $12,500 OOP Maximum (in-network/out-of-network) $11,000 $13,200 $13,200 Other Considerations Other Consideration: out-of-network coverage? û û ü Other Consideration: Other Consideration: Scenario 2: the Green Family (family of 5)
  • 89.
    89 Copays/Coinsurance Amount AmountAmount Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes) Primary Care Provider (PCP) visit no charge ü $40 T1: $15, T2: $50 ~ Specialist visit no charge ü $150 $75 for 1/$75 ~ Prescriptions Generic drugs no charge ü $20 T1 & 2: $20 Preferred brand name drugs no charge ü $80 T1 & 2: $45 ü Non-preferred brand name drugs no charge ü $150 T1 & 2: $75 ü Specialty drugs no charge ü 20% ü T1 & 2: 40% ü Emergency Room (ER) visit no charge ü 20% ü $250 for 2/$250 ~ Inpatient hospital stay no charge ü 20% ü T1: $250, T2: $500 ü Option 1 Option 2 Option 3 Insurance company Consumers’ Choice Consumers’ Choice Coventry Health plan name Bronze HDP 1 Bronze 10 Bronze $15 Copay Upstate Plan type (HMO, PPO, POS, EPO, or other) EPO EPO POS Monthly premium (after tax credit) $0 $13 $56 Deductible (in-network/out-of-network) $11,000 $12,600 T1: $10,000/T2: $12,500 OOP Maximum (in-network/out-of-network) $11,000 $13,200 $13,200 Other Considerations Other Consideration: out-of-network coverage? û û ü Other Consideration: Spanish speaking PCPs Other Consideration: Scenario 2: the Green Family (family of 5)
  • 90.
    Scenario 2: theGreen Family (family of 5) 90
  • 91.
    Scenario 2: theGreen Family (family of 5) 91
  • 92.
    Scenario 2: theGreen Family (family of 5) 92
  • 93.
    Scenario 2: theGreen Family (family of 5) 93
  • 94.
    94 Copays/Coinsurance Amount AmountAmount Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes) Primary Care Provider (PCP) visit no charge ü $40 T1: $15, T2: $50 ~ Specialist visit no charge ü $150 $75 for 1/$75 ~ Prescriptions Generic drugs no charge ü $20 T1 & 2: $20 Preferred brand name drugs no charge ü $80 T1 & 2: $45 ü Non-preferred brand name drugs no charge ü $150 T1 & 2: $75 ü Specialty drugs no charge ü 20% ü T1 & 2: 40% ü Emergency Room (ER) visit no charge ü 20% ü $250 for 2/$250 ~ Inpatient hospital stay no charge ü 20% ü T1: $250, T2: $500 ü Option 1 Option 2 Option 3 Insurance company Consumers’ Choice Consumers’ Choice Coventry Health plan name Bronze HDP 1 Bronze 10 Bronze $15 Copay Upstate Plan type (HMO, PPO, POS, EPO, or other) EPO EPO POS Monthly premium (after tax credit) $0 $13 $56 Deductible (in-network/out-of-network) $11,000 $12,600 T1: $10,000/T2: $12,500 OOP Maximum (in-network/out-of-network) $11,000 $13,200 $13,200 Other Considerations Other Consideration: out-of-network coverage? û û ü Other Consideration: Spanish speaking PCPs Other Consideration: Scenario 2: the Green Family (family of 5)
  • 95.
    95 Copays/Coinsurance Amount AmountAmount Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes) Primary Care Provider (PCP) visit no charge ü $40 T1: $15, T2: $50 ~ Specialist visit no charge ü $150 $75 for 1/$75 ~ Prescriptions Generic drugs no charge ü $20 T1 & 2: $20 Preferred brand name drugs no charge ü $80 T1 & 2: $45 ü Non-preferred brand name drugs no charge ü $150 T1 & 2: $75 ü Specialty drugs no charge ü 20% ü T1 & 2: 40% ü Emergency Room (ER) visit no charge ü 20% ü $250 for 2/$250 ~ Inpatient hospital stay no charge ü 20% ü T1: $250, T2: $500 ü Option 1 Option 2 Option 3 Insurance company Consumers’ Choice Consumers’ Choice Coventry Health plan name Bronze HDP 1 Bronze 10 Bronze $15 Copay Upstate Plan type (HMO, PPO, POS, EPO, or other) EPO EPO POS Monthly premium (after tax credit) $0 $13 $56 Deductible (in-network/out-of-network) $11,000 $12,600 T1: $10,000/T2: $12,500 OOP Maximum (in-network/out-of-network) $11,000 $13,200 $13,200 Other Considerations Other Consideration: out-of-network coverage? û û ü Other Consideration: Spanish speaking PCPs 19 (10 mi.) 26 (20 mi.) 19 (10 mi.) 26 (20 mi.) T1: 46, T2: 15 (10 mi.) Other Consideration: Scenario 2: the Green Family (family of 5)
  • 96.
    Scenario 2: theGreen Family (family of 5) 96
  • 97.
    Scenario 2: theGreen Family (family of 5) 97
  • 98.
    98 Copays/Coinsurance Amount AmountAmount Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes) Primary Care Provider (PCP) visit no charge ü $40 T1: $15, T2: $50 ~ Specialist visit no charge ü $150 $75 for 1/$75 ~ Prescriptions Generic drugs no charge ü $20 T1 & 2: $20 Preferred brand name drugs no charge ü $80 T1 & 2: $45 ü Non-preferred brand name drugs no charge ü $150 T1 & 2: $75 ü Specialty drugs no charge ü 20% ü T1 & 2: 40% ü Emergency Room (ER) visit no charge ü 20% ü $250 for 2/$250 ~ Inpatient hospital stay no charge ü 20% ü T1: $250, T2: $500 ü Option 1 Option 2 Option 3 Insurance company Consumers’ Choice Consumers’ Choice Coventry Health plan name Bronze HDP 1 Bronze 10 Bronze $15 Copay Upstate Plan type (HMO, PPO, POS, EPO, or other) EPO EPO POS Monthly premium (after tax credit) $0 $13 $56 Deductible (in-network/out-of-network) $11,000 $12,600 T1: $10,000/T2: $12,500 OOP Maximum (in-network/out-of-network) $11,000 $13,200 $13,200 Other Considerations Other Consideration: out-of-network coverage? û û ü Other Consideration: Spanish speaking PCPs 19 (10 mi.) 26 (20 mi.) 19 (10 mi.) 26 (20 mi.) T1: 46, T2: 15 (10 mi.) Scenario 2: the Green Family (family of 5)
  • 99.
    99 Copays/Coinsurance Amount AmountAmount Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes) Primary Care Provider (PCP) visit no charge ü $40 Specialist visit no charge ü $150 Prescriptions Generic drugs no charge ü $20 Preferred brand name drugs no charge ü $80 Non-preferred brand name drugs no charge ü $150 Specialty drugs no charge ü 20% ü Emergency Room (ER) visit no charge ü 20% ü Inpatient hospital stay no charge ü 20% ü Option 1 Option 2 Option 3 Insurance company Consumers’ Choice Consumers’ Choice Health plan name Bronze HDP 1 Bronze 10 Plan type (HMO, PPO, POS, EPO, or other) EPO EPO Monthly premium (after tax credit) $0 $13 Deductible (in-network/out-of-network) $11,000 $12,600 OOP Maximum (in-network/out-of-network) $11,000 $13,200 Other Considerations Other Consideration: out-of-network coverage? û û Other Consideration: Spanish speaking PCPs 19 (10 mi.) 26 (20 mi.) 19 (10 mi.) 26 (20 mi.) Scenario 2: the Green Family (family of 5)
  • 100.
    10 0 Copays/Coinsurance Amount AmountAmount Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes) Primary Care Provider (PCP) visit no charge ü $40 $10 Specialist visit no charge ü $150 20% ü Prescriptions Generic drugs no charge ü $20 $10 Preferred brand name drugs no charge ü $80 20% ü Non-preferred brand name drugs no charge ü $150 20% ü Specialty drugs no charge ü 20% ü 20% ü Emergency Room (ER) visit no charge ü 20% ü 20% ü Inpatient hospital stay no charge ü 20% ü 20% ü Option 1 Option 2 Option 3 Insurance company Consumers’ Choice Consumers’ Choice Consumers’ Choice Health plan name Bronze HDP 1 Bronze 10 Silver 10 Plan type (HMO, PPO, POS, EPO, or other) EPO EPO EPO Monthly premium (after tax credit) $0 $13 $167 Deductible (in-network/out-of-network) $11,000 $12,600 $1,000 OOP Maximum (in-network/out-of-network) $11,000 $13,200 $3,000 Other Considerations Other Consideration: out-of-network coverage? û û û Other Consideration: Spanish speaking PCPs 19 (10 mi.) 26 (20 mi.) 19 (10 mi.) 26 (20 mi.) 19 (10 mi.) 26 (20 mi.) Scenario 2: the Green Family (family of 5)
  • 101.
    10 1 Copays/Coinsurance Amount Amount Deductibleapplies? (check if yes) Deductible applies? (check if yes) Primary Care Provider (PCP) visit no charge ü $10 Specialist visit no charge ü 20% ü Prescriptions Generic drugs no charge ü $10 Preferred brand name drugs no charge ü 20% ü Non-preferred brand name drugs no charge ü 20% ü Specialty drugs no charge ü 20% ü Emergency Room (ER) visit no charge ü 20% ü Inpatient hospital stay no charge ü 20% ü Option 1 Option 3 Insurance company Consumers’ Choice Consumers’ Choice Health plan name Bronze HDP 1 Silver 10 Plan type (HMO, PPO, POS, EPO, or other) EPO EPO Monthly premium (after tax credit) $0 $167 Deductible (in-network/out-of-network) $11,000 $1,000 OOP Maximum (in-network/out-of-network) $11,000 $3,000 Other Considerations Other Consideration: out-of-network coverage? û û Other Consideration: Spanish speaking PCPs 19 (10 mi.) 26 (20 mi.) 19 (10 mi.) 26 (20 mi.) Scenario 2: the Green Family (family of 5) $0 $2,004 Annual Cost Annual Cost $6,400 $6,400 $40 $480 $4,124 $600 Health care needs: •  PCP checkup every 3 months ($120/visit) •  Four generic prescriptions per month ($40 retail) •  Hospitalization ($4,000 bill) $1,000
  • 102.
    Identify the GreenFamily’s Priorities for Insurance •  Cheapest monthly payment? •  Manageable deductible? •  Low copays/coinsurance? •  Having “first dollar” coverage? (i.e. some services exempt from the deductible?) •  Current doctor in network? •  Size of network •  Prescription drugs covered? •  Out-of-network coverage? •  Language spoken by providers? •  Lowest overall annual cost (premiums + anticipated cost-sharing) 10 2
  • 103.
  • 104.
    Assisting Consumers inPlan Selection 10 4
  • 105.
    Scenario 1: Sasha(Tampa Bay Lightning Fan) 10 5 Sasha   Age   37   County   Hillsborough  County,  FL   Zip  Code   33601   Income   $25,000   Federal  Poverty  Level   212%   Employer  coverage?   no   APTC   $139.62/month   Cost-­‐sharing  ReducCons?   Yes  (Silver  73%)   Priorities •  Very concerned about cost •  Doesn’t have a specific doctor •  Has one prescription medication (generic)
  • 106.
    B1   B2   B3   B4   QHPs available to Sasha (Tampa, FL) - Bronze 10 6
  • 107.
    QHPs available toSasha (Tampa, FL) - Bronze 10 7 B5   B6   B7  
  • 108.
    S1   S2   S3   S4   QHPs available to Sasha (Tampa, FL) - Silver 10 8
  • 109.
    S5   S5   S7   QHPs available to Sasha (Tampa, FL) - Silver 10 9
  • 110.
    Scenario 2: Jillianand Michael (Chicago fans) 11 0 Jillian   Michael   Age   55   55   County   Cook  County,  IL   Zip  Code   60609   Income   $22,800   $7,200   Federal  Poverty  Level   188%   Employer  coverage?   no   no   APTC   $603.77/month   Cost-­‐sharing  ReducCons?   Yes  (Silver  87%)  
  • 111.
    Scenario 2: Jillianand Michael (Chicago fans) 11 1
  • 112.
    Contact Info Dave Chandra SeniorPolicy Analyst 202-408-1080 chandra@cbpp.org For more information and resources, please visit: www.healthreformbeyondthebasics.org a  project  of  the  Center  on  Budget  and  Policy  PrioriRes,  www.cbpp.org     11 2
  • 113.
    113 New Training Resources • Highly customized, Action-oriented •  New suite of training services •  Goal-setting •  Planning •  Coaching •  In-person training •  FOR MORE INFO – training@enrollamerica.org