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Open Enrollment is November 1st to January 31st
California is the first State in the Nation to enact legislation under the
Affordable Care Act.
Beginning October 1st, 2013, Californians will be able to purchase health care insurance regardless of any pre-existing health conditions. Even if you're sick, you cannot be denied coverage nor have your coverage cancelled due to pre-existing condition.
Four new health plans have been created.
They're called the metal plans: Bronze, Silver, Gold and Platinum. These plans are available through a couple of basic sources: Directly from health insurance companies via your insurance agent or through an Exchange created by the State of California. The plans "on exchange" are identical to the plans "off exchange" through your insurance agent. Here's some terminology to help guide you:
The plans off the exchange are available directly from the health insurance companies such as Anthem Blue Cross or Blue Shield of CA.
What's the percentage of coverage in each plan?
Platinum = 90% coverage. You pay 10%
Gold = 80% coverage. You pay 20%
Silver = 70% coverage. You pay 30%
Bronze = 60% coverage. You pay 40%
Why buy a plan on the Exchange?
Again, plans on & off have the same coverages, co-pays, deductibles and premium! Then, what's the difference? If an individual or family needs to obtain a subsidy from the federal government, then apply with your agent for a plan "On the Exchange." Use an agent. This stuff is confusing. "Certified Agents" have received in-class and on-line training to guide consumers, plus have passed a mandatory test to reach Certification Status. There is no additional cost when using a Certified Insurance Agent.
What is a Subsidy?
The Affordable Care Act (ACA or health care reform law) set up premium and cost-sharing subsidies to help individuals and families pay for their coverage. They can qualify for these subsidies only if they meet certain income rules and buy on the exchange. If they buy a plan sold off the exchange, they will not get any subsidy. But if they don’t buy any coverage at all, they may face a tax penalty.
Premium subsidies are in fact tax credits. People can apply all or part of the credit they’re due to help lower the cost of their health plan. The exchange sends the tax credit directly to the insurance company, so the person pays less for premiums each month. This is called advance payment of the premium tax credit or APTC.
If the advance payments applied to a year’s worth of premiums end up being less than the tax credit, the person may get a refund credit after filing a federal income tax return. But if the advance payments are more than the tax credit, the person must repay the excess amount at tax time.
Do all the plans offer the Federal Subsidy?
Yes. Plans purchased only through the California State Exchange allow for the subsidy. Depending on your income, the premium, co-payments, prescription deductible, and the maximum Out-Of-Pocket for One and for Family will be based on a sliding scale. The Silver Plan is the only plan that offers the greatest flexibility in terms of copayments and deductibles. If you qualify, instead of the usual $45 charge for a Primary Care Visit, your copay for this service could be as low as $3.00. Again, it's subject to your income.
What are some more plan differences?
The Bronze and Silver plans are the lowest priced plans, but are the only two plans with deductibles. The Bronze has a $5,000 deductible for Medical and Drugs. The Silver plan has a $2,000 Medical Deductible. The Gold and Platinum plans don't have any deductibles. A deductible is the amount of money you pay first, before medical or drug services or goods are rendered. Additionally, Silver plans will have a sliding co-pay and premium scale based on your income.
What types of network plans are available?
There's PPO, HMO, EPO, and HSA plans. A PPO is a Preferred Provider Organization plan. Basically, you have the autonomy to choose your health care provider within the network and see a Specialist without a referral. An HMO requires you to see your primary physician. In order to see a Specialist, you must get a referral from your Primary HMO Doctor.
An EPO is like a PPO. EPO stands for Exclusive Provider Network. You don't need a referral to see a Specialist within the network of doctors. However, hospital benefits are tiered. In other words, copays may differ from one hospital to another. Plus, you may only use the doctors/hospitals within that region. An example of a region would be Orange County, CA.
EPOs involve tiered hospital benefits. A Tier 1 hospital is a Preferred Participating Hospitals. That means, assuming you have met your deductible, you will pay your regular coinsurance on your plan. For example, it may be 20% after deductible. There are some hospitals that are Tier 2, that simply means they are Participating, but not “preferred”. Tier 2 is still a network hospital, however, you will pay a higher coinsurance, for example 50%. Whether you go to Tier 1 or Tier 2 hospitals – the coinsurance you pay will apply toward your out of pocket maximum on your plan.
Moreover, with an EPO, you have the freedom to choose any provider that is part of the PATHWAY EPO/PPO network. Again, the “E” stands for Exclusive, and when Anthem says Exclusive – that means you want to exclusively select Pathway network providers to have the protection of Anthem’s strong negotiated rate and full benefits of your plan. Again no referrals, no primary physician required…YOU CHOOSE WHERE YOU WANT TO GO IN THE NETWORK! However, if you go to a non-network provider, you will be responsible for the medical bill, because Anthem does not have contracts with non-network providers.
HSA plans are Health Savings accounts. These plans are designed for Self-Employed people looking to use pre-tax dollars towards their medical expenses.
What if I already have a plan, do I have to switch?
If you purchased an individual or family plan prior to March 2010, before the ACA was signed into law, then you may keep your plan. If you bought a plan after this date, your plan will be automatically switched to a new ACA compliant plan effective 1/1/2014. If you don't like the new plan, you do have the option to choose a another ACA plan.
Should I keep my old plan or get a new one?
The advantage to keeping your old plan is the ability of having out-of-network coverage. If you happen to get sick while traveling, then under your old plan, you do have coverage. Under the new metal plans, there's only coverage in life threatening situations.
How often can I switch plans?
You can switch plans during the Open Enrollment period. This will allow people sufficient time to research and select a new plan. Thereafter, open enrollment starts in November for January 1st policy effective dates.
Can I buy a plan any other time of the year besides Open Enrollment?
Yes, as long as you meet certain conditions known as a "qualifying event." Individuals will have 60 calendar days from the date of a qualifying event to enroll in a plan. Documentation / proof of the qualifying event is required. Learn more...
What are the Qualifying Events for plans "on" the exchange?
If an individual loses their Minimum Essential Coverage due to: legal separation or divorce, no longer a dependent, death of an employee, termination of employment, reduction in the number of hours of employment, you no longer reside or work in the Health Plan's Service Area, termination of employer contributions, exhaustion of COBRA benefits, if you gain a dependent through marriage, birth or adoption and if you become a US citizen.
What are the Qualifying Events for plans "off" the exchange?
If a person loses their Minimum Essential Coverage due to: marriage, divorce, adoption or birth.
If all the plans have the same coverages, then what are the differences between companies?
All the insurance are mandated to provide the same template of coverages. There are two main differences: Network of Doctors/Hospitals and Price. California has been divided into 19 regions. Not all the plans are available in each region. For example, Anthem Blue Cross is no longer offering a PPO plan in Los Angeles nor Orange County, CA. Try Blue Shield.
I have Medicare, do I need to switch?
Nope. Medicare plans are unaffected under the new law. However, some insurance are reducing the number of medicare plans that they have available. For example, if you have an Anthem Blue Cross Plan F with a High Deductible, then get ready. Anthem Blue Cross is dissolving this plan.
What's the cost and what are my choices of plans?
Start here: Get a quote or apply for coverage Unlike in previous years, the new metal plan premiums will change every year that you get older. The old style Traditional Plans were age band rated meaning that rates for an individual changed every 5 years. You have 4 choices of plans to choose from: Bronze, Silver, Gold and Platinum. Contact our office for guidance at 1-888-737-6200.
Four new health plans have been created.
They're called the metal plans: Bronze, Silver, Gold and Platinum. These plans are available through a couple of basic sources: Directly from health insurance companies via your insurance agent or through an Exchange created by the State of California. The plans "on exchange" are identical to the plans "off exchange" through your insurance agent. Here's some terminology to help guide you:
The plans off the exchange are available directly from the health insurance companies such as Anthem Blue Cross or Blue Shield of CA.
What's the percentage of coverage in each plan?
Platinum = 90% coverage. You pay 10%
Gold = 80% coverage. You pay 20%
Silver = 70% coverage. You pay 30%
Bronze = 60% coverage. You pay 40%
Why buy a plan on the Exchange?
Again, plans on & off have the same coverages, co-pays, deductibles and premium! Then, what's the difference? If an individual or family needs to obtain a subsidy from the federal government, then apply with your agent for a plan "On the Exchange." Use an agent. This stuff is confusing. "Certified Agents" have received in-class and on-line training to guide consumers, plus have passed a mandatory test to reach Certification Status. There is no additional cost when using a Certified Insurance Agent.
What is a Subsidy?
The Affordable Care Act (ACA or health care reform law) set up premium and cost-sharing subsidies to help individuals and families pay for their coverage. They can qualify for these subsidies only if they meet certain income rules and buy on the exchange. If they buy a plan sold off the exchange, they will not get any subsidy. But if they don’t buy any coverage at all, they may face a tax penalty.
Premium subsidies are in fact tax credits. People can apply all or part of the credit they’re due to help lower the cost of their health plan. The exchange sends the tax credit directly to the insurance company, so the person pays less for premiums each month. This is called advance payment of the premium tax credit or APTC.
If the advance payments applied to a year’s worth of premiums end up being less than the tax credit, the person may get a refund credit after filing a federal income tax return. But if the advance payments are more than the tax credit, the person must repay the excess amount at tax time.
Do all the plans offer the Federal Subsidy?
Yes. Plans purchased only through the California State Exchange allow for the subsidy. Depending on your income, the premium, co-payments, prescription deductible, and the maximum Out-Of-Pocket for One and for Family will be based on a sliding scale. The Silver Plan is the only plan that offers the greatest flexibility in terms of copayments and deductibles. If you qualify, instead of the usual $45 charge for a Primary Care Visit, your copay for this service could be as low as $3.00. Again, it's subject to your income.
What are some more plan differences?
The Bronze and Silver plans are the lowest priced plans, but are the only two plans with deductibles. The Bronze has a $5,000 deductible for Medical and Drugs. The Silver plan has a $2,000 Medical Deductible. The Gold and Platinum plans don't have any deductibles. A deductible is the amount of money you pay first, before medical or drug services or goods are rendered. Additionally, Silver plans will have a sliding co-pay and premium scale based on your income.
What types of network plans are available?
There's PPO, HMO, EPO, and HSA plans. A PPO is a Preferred Provider Organization plan. Basically, you have the autonomy to choose your health care provider within the network and see a Specialist without a referral. An HMO requires you to see your primary physician. In order to see a Specialist, you must get a referral from your Primary HMO Doctor.
An EPO is like a PPO. EPO stands for Exclusive Provider Network. You don't need a referral to see a Specialist within the network of doctors. However, hospital benefits are tiered. In other words, copays may differ from one hospital to another. Plus, you may only use the doctors/hospitals within that region. An example of a region would be Orange County, CA.
EPOs involve tiered hospital benefits. A Tier 1 hospital is a Preferred Participating Hospitals. That means, assuming you have met your deductible, you will pay your regular coinsurance on your plan. For example, it may be 20% after deductible. There are some hospitals that are Tier 2, that simply means they are Participating, but not “preferred”. Tier 2 is still a network hospital, however, you will pay a higher coinsurance, for example 50%. Whether you go to Tier 1 or Tier 2 hospitals – the coinsurance you pay will apply toward your out of pocket maximum on your plan.
Moreover, with an EPO, you have the freedom to choose any provider that is part of the PATHWAY EPO/PPO network. Again, the “E” stands for Exclusive, and when Anthem says Exclusive – that means you want to exclusively select Pathway network providers to have the protection of Anthem’s strong negotiated rate and full benefits of your plan. Again no referrals, no primary physician required…YOU CHOOSE WHERE YOU WANT TO GO IN THE NETWORK! However, if you go to a non-network provider, you will be responsible for the medical bill, because Anthem does not have contracts with non-network providers.
HSA plans are Health Savings accounts. These plans are designed for Self-Employed people looking to use pre-tax dollars towards their medical expenses.
What if I already have a plan, do I have to switch?
If you purchased an individual or family plan prior to March 2010, before the ACA was signed into law, then you may keep your plan. If you bought a plan after this date, your plan will be automatically switched to a new ACA compliant plan effective 1/1/2014. If you don't like the new plan, you do have the option to choose a another ACA plan.
Should I keep my old plan or get a new one?
The advantage to keeping your old plan is the ability of having out-of-network coverage. If you happen to get sick while traveling, then under your old plan, you do have coverage. Under the new metal plans, there's only coverage in life threatening situations.
How often can I switch plans?
You can switch plans during the Open Enrollment period. This will allow people sufficient time to research and select a new plan. Thereafter, open enrollment starts in November for January 1st policy effective dates.
Can I buy a plan any other time of the year besides Open Enrollment?
Yes, as long as you meet certain conditions known as a "qualifying event." Individuals will have 60 calendar days from the date of a qualifying event to enroll in a plan. Documentation / proof of the qualifying event is required. Learn more...
What are the Qualifying Events for plans "on" the exchange?
If an individual loses their Minimum Essential Coverage due to: legal separation or divorce, no longer a dependent, death of an employee, termination of employment, reduction in the number of hours of employment, you no longer reside or work in the Health Plan's Service Area, termination of employer contributions, exhaustion of COBRA benefits, if you gain a dependent through marriage, birth or adoption and if you become a US citizen.
What are the Qualifying Events for plans "off" the exchange?
If a person loses their Minimum Essential Coverage due to: marriage, divorce, adoption or birth.
If all the plans have the same coverages, then what are the differences between companies?
All the insurance are mandated to provide the same template of coverages. There are two main differences: Network of Doctors/Hospitals and Price. California has been divided into 19 regions. Not all the plans are available in each region. For example, Anthem Blue Cross is no longer offering a PPO plan in Los Angeles nor Orange County, CA. Try Blue Shield.
I have Medicare, do I need to switch?
Nope. Medicare plans are unaffected under the new law. However, some insurance are reducing the number of medicare plans that they have available. For example, if you have an Anthem Blue Cross Plan F with a High Deductible, then get ready. Anthem Blue Cross is dissolving this plan.
What's the cost and what are my choices of plans?
Start here: Get a quote or apply for coverage Unlike in previous years, the new metal plan premiums will change every year that you get older. The old style Traditional Plans were age band rated meaning that rates for an individual changed every 5 years. You have 4 choices of plans to choose from: Bronze, Silver, Gold and Platinum. Contact our office for guidance at 1-888-737-6200.
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Medical, Dental & Vision
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Medical, Dental & Vision
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