In order to pick the right health insurance plan you have to understand what the Obamacare health plans are. We’ll show you which plans are the most popular, and then help you understand the main benefits of each health plan. We’ll give you some ideas about which plans are a good fit for specific health situations. Then we’ll compare the plans side by side so you can easily see what is different. With this information you can make an informed choice about the best health plan for you or your family. Get quotes below, or in the Quote Center to the right.[/jcolumns]
Covered California Health Plan Enrollment 2016: Which Plans Are Most Popular?
Covered California reports which metal plans people have signed up for as of October 2015. It is not surprising that the Silver plans received the most subscribers. Our experience at SPF Insurance is very similar.
Bronze plans were a distance second place. Gold and Platinum plans totaled just under 10 percent, and almost nobody signed up for a Minimum Coverage plan. You’ll see why these results happen as we go over the metal plan benefits below.
2016 Health Care Reform Metal Plan Benefit Descriptions
There are 5 primary plans in California: Bronze, Silver, Gold, Platinum, and a Minimum Coverage (Catastrophic) plan that’s available to those under the age of 30. On Covered California only the base metal plans are offered. Outside of the exchange or marketplace, the health insurance companies are required to offer the same base plans, but they are allowed to offer slight variations of those plans as well.
If we consider just the base plans designs on the California exchange, then there are 8 specific plan designs.
- Minimum Coverage Catastrophic – 1 design
- Bronze – 2 designs (1 HSA plan, 1 regular plan)
- Silver – 1 design
- Gold – 2 designs (1 Co-pay plan, 1 Co-insurance plan)
- Platinum – 2 designs (1 Co-pay plan, 1 Co-insurance plan}
Depending upon the insurance company, these 8 designs are offered with either PPO, EPO, HSP, or HMO provider networks. Regardless of the network type, the benefits of base metal plans are identical from one insurance company to the next. For example, a Silver plan from Anthem Blue Cross has the same benefits as a Silver plan from Blue Shield or Health Net. The only difference is the network and the price of the plan.
The price of plans on Covered California and outside of Covered California are identical. For example, a Blue Shield Silver PPO plan on Covered California costs the same amount if you get it directly from Blue Shield.
Each health insurance company has ONE network of doctors that is used for plans purchased on Covered California and for plans purchased directly from the insurance company. Therefore, doctors can not tell you they “don’t take the Covered California version of your health plan.”
In the descriptions below, we will describe the base plan designs.
Minimum Coverage Health Plan Details & Benefits
The Catastrophic plan provides limited benefits and the highest deductible and out-of-pocket maximum of all the health care reform plans. Like all the other metal plans, the Catastrophic plan provides preventive care and three office visits at $0 cost. The rest of the Catastrophic health plan benefits are shown below.
As you can see, this plan provides no other benefits until you reach the $6,850 out-of-pocket (OOP) maximum. On Covered California this plan is called the “Minimum Coverage” plan.
The Minimum Coverage plan is only available to people under the age of 30, or those that have received a hardship exemption from having to pay the mandate penalty for not having health insurance. Catastrophic plan applicants age 30 and older are required to:
- Submit a hardship exemption application to the federal Marketplace (click link above). If approved, the Marketplace will send you a notice with your exemption certificate number (ECN)
- Include the Marketplace notice and your ECN along with your application for Catastrophic coverage
- You’ll have to provide proof of your hardship exemption every year. You’ll need to re-apply for a hardship exemption from the Marketplace, and submit the Marketplace notice with the new ECN to your insurance company every year – by January 1 – in order to keep your catastrophic plan.
Catastrophic plans are good for situations where you are healthy and cost is king, so minimizing cost is important. It’s not a good fit for anyone that has ongoing medical needs or prescriptions.
Bronze Health Plan Details & Benefits
The Bronze plans are slightly better than the Minimum Coverage plan. There are two versions of the Bronze plan. A Health Savings Account (HSA) compatible plan and a regular plan. Go to this page for more details about what HSA health insurance plans are and how they work.
The regular Bronze design has the benefits shown below. All Bronze plans provide $0 cost preventive care.
In a Bronze plan you get 3 office visits for a simple $70 co-pay. Other than that, the insurance company pays for no additional benefits until you reach the deductible.
Although the Bronze plan has a $6,000 deductible, the insurance company will not begin paying for any of your medical expenses until you reach the Out-Of-Pocket maximum of $6,500. If something significant happens to you and you meet the deductible of $6,000, all additional office visits become a co-payment. Once your payments for medical expenses reach $6,500, the insurance company begins paying 100% for all additional medical expenses you have that year.
The Bronze HSA compatible plan has the benefits shown below. Again, all preventive care is provided at $0 cost to you.
The Bronze HSA plan provides no benefits until you reach the $4,500 deductible. If your medical costs are greater than $4,500, then you will begin sharing costs with the insurance company. You will pay 40% (your co-insurance amount) and the insurance company will pay the remaining 60% of your medical expenses. Once your total out-of-pocket costs equal $6,500 you are done and the insurance company will pay 100% of any additional costs for the year.
Both Bronze health plan details are what I would call safety-net plans, and should only be used if you are healthy and have no medical needs except for regular preventive care. If you have some generic prescriptions and no brand name medications, a Bronze plan might be a good fit if the cost difference between the Bronze and Silver plans is less than the monthly cost of your medications.
Silver Health Plan Details & Benefits
The Silver health plans are the most popular in California. This is probably because Silver offers the level of benefits that most people want in their health insurance.
The basic Silver plan provides unlimited office visits for a $45 co-pay. Any lab tests ordered by the doctor are a $35 co-pay, x-rays are a $65 co-pay, and these are great benefits for a PPO or HMO type Silver plan. In 2013, PPO plans would require that you pay for any lab tests or x-rays as part of your yearly deductible.
Generic prescription coverage is provided for a $15 co-pay, and brand name drugs are covered with a $50 co-pay after you meet a smaller $250 brand name deductible.
If something major occurs then you are required to meet the $2,250 deductible before the insurance company begins paying for most of your benefits. All office visits, lab tests, and drug co-pays count towards your deductible. Once your payments for medical expenses equal the deductible amount, you begin sharing costs with the insurance company. You pay a 20% co-insurance and the insurance company pays the remaining 80% of the expenses.
The insurance company will pay 100% for all additional expenses once your total out-of-pocket expense equals $6,250.
Silver plans offer the best mix of benefits and monthly premiums (cost). Because of that, Silver is a good option for people that take medications and/or want to make sure they can see a doctor whenever they need to. As you can imagine, that last point describes what new parents want for their baby, so Silver is a great choice for newborns.
Cost-Share Reduction Silver Plans
There are some special Silver plans that you can qualify for if your income is between 100% and 250% of the Federal Poverty Level. This table outlines the benefits of these plans versus the standard Silver plan described above.
If you qualify for an enhanced cost-share reduction plan, you really should take it. For the price of a regular Silver plan you may get a plan with benefits equal to or better than a Gold or Platinum plan.
Gold Health Plan Details & Benefits
Gold health plans are the first ones that have $0 deductibles. There are two versions of the gold plan. The co-pay version and the co-insurance version. We’ll show the differences below.
The co-insurance Gold plan has no deductible. Office visits and lab tests are a $35 co-pay, x-rays are a $50 co-pay, generic prescriptions are a $15 co-pay, and brand name prescriptions are a $50 co-pay (there is no brand name prescription deductible you have to meet before having a co-pay).
Gold health insurance plans are considered “first dollar coverage” because they have no deductible. If a major medical event happens to you, the cost is shared and the insurance company pays 80% of the cost and you pay 20%. This will continue until you reach the $6,200 out-of-pocket maximum for the policy. At that point the insurance company will pay for everything else.
The design of the Gold Co-Insurance Plan is most similar to a PPO type plan. However, this Gold version is offered by multiple carriers and some use a PPO network while others use an HMO network.
This PPO version of the Gold plan is a good fit if you want the ability to select and go see an in-network specialist without having to get a referral from your primary doctor. The other situation is if you do not want to be responsible for a deductible before the insurance company begins to pay for medical services. This can be a good fit for “accident prone” children, teenagers, or active adults.
The only difference between the Co-Pay and the Co-Insurance version of the Gold plan is that the Co-Pay version has a co-pay for hospital and outpatient services instead of a co-insurance rate. The diagram below illustrates this by removing the co-insurance, and adding a couple of larger co-pays.
In the Gold Co-Pay health plan the 20% co-insurance for in-hospital care goes away. It is replaced by a fixed $600/day (up to 5 days) co-pay for hospital and outpatient surgery care. To reach the $6,200 out-of-pocket maximum you would need to be admitted to the hospital twice for five days each time. This makes the co-pay version of the plan more advantageous than the co-insurance version.
Because of the fixed co-pay for in-hospital or out-patient treatment, the Gold Co-pay plan is a good fit if you know you need to have a medically necessary surgery (health insurance will not pay for cosmetic surgery). You should compare the cost to have the surgery in the Silver plan versus the cost in the Gold Co-Pay plan to determine which will be lower cost, including the monthly premiums.
Platinum Health Plan Details & Benefits
The Platinum health plan has the richest benefits. There are also two versions of the Platinum plan just like Gold had. A PPO-like Co-Insurance version and an HMO-like Co-Pay version.
The main difference between the Gold and Platinum versions is that the Platinum level has lower co-pays and lower co-insurance, and the Platinum level has a $4,000 out-of-pocket maximum.
The Platinum Co-Insurance health plan offers unlimited office visits for a $20 co-pay. Lab tests are a $20 co-pay. X-rays are a $40 co-pay, and generic prescriptions are a $5 co-pay. Brand name prescriptions are provided with a $15 co-pay.
If something major occurs, and you have an outpatient surgery or are admitted to the hospital, then you will pay a 10% co-insurance. This will continue until the total of all your co-pays and co-insurance equal the $4,000 out-of-pocket maximum. At that point, the health insurance company will pay 100% for all additional medical expenses.
Co-Insurance Platinum plans may be a good fit if you take multiple medications and the prescription co-payment savings is greater than the higher monthly premium of the Platinum Co-Insurance plan versus the Silver or Gold plan preimums. At the platinum level, the co-insurance version is not as good as the co-pay version (you’ll see why in the description of the co-pay plan). Therefore, the only reason to pick this Platinum version is if your doctor is only in this plan’s network.
This is a good plan if you know you have a lot of chronic condition maintenance needs, such as office visits, tests, and medications. The other use for these plans is for maternity coverage in California, especially the delivery.
The Platinum Co-Payment Health Plan is the richest benefit level available. The Co-Pay version has the same office visit, lab test, x-ray, and prescription drug coverage co-pays as the Co-Insurance version of Platinum.
The best part of this Platinum version is that for hospital and out-patient surgery care you have a $250/day co-pay (5 days maximum). No matter what the reason, or what the cost is, if you are admitted to the hospital your total cost will be $1,250 (5 days times $250). The health insurance company will pay for all other hospital costs.
Because of this co-pay arrangement, the Platinum Co-Payment plan is the best Obamacare plan.
This is the primary maternity option for expecting mothers. The hospital co-pay will typically limit your out-of-pocket cost for the delivery to just $500 (2 days for a vaginal birth). This is also a good plan if you know you will need to spend time in the hospital while receiving treatments.
For chronic conditions that require many office visits and multiple prescriptions, the Platinum Co-Payment can be the best option.
Get more specific and detailed situation and health insurance recommendations here.
Detail Comparison Of The Health Care Reform Health Plans
Here is how all the Covered California plans stack up to each other. The table below shows the detailed side-by-side comparison of the Catastrophic, Bronze, Silver, Gold, and Platinum plans we’ve described above.
As you look at the comparison, you can begin to see why Silver is the most popular choice in California. Other than something major, the majority of Silver benefits are just a co-pay and there are no limits on the number of office visits. The Silver plan fits what most people are looking for in health insurance.
You can see what your cost for a Silver plan is by running a quote below.
California Table of Obamacare Health Plans
There are more than 80 Obamacare health insurance plans available in California. We’ve created separate analysis pages for each insurance company. On each page you’ll find a great tabular overview of that company’s health plans. We’ll then analyze the provider networks, the plans and pricing, and give you our recommendations about how to use the plans from that company. Just click on the insurance company name below to go to that analysis page.
- Anthem Blue Cross
- Blue Shield of California
- Health Net
- Kaiser Permanente
- Molina Healthcare
- Sharp Health Plan
- United Healthcare
Overview Of What California Health Care Reform Is
Learn more about Subsidies, Premium Assistance, and see if your income qualifies you to get help paying your monthly premiums by clicking here.