Health and Medical information can take many different turns and twits in this year of change with Obama Care or the Affordable Care Act. Today, Californians are faced with the choice of purchasing health insurance for their medical needs through their employer’s program – if they are so lucky to have a position that includes this benefit; purchase coverage in the “Exchange” or Covered California – the State’s counter part of the Obama Care; or lastly purchase coverage outside the Exchange on the open market.
Properly evaluating these options, it is necessary to be aware of the differences between programs. You can make the best choices based on your health and medical information with a few definitions of terms used to describe these plans. These terms are:
* Participating Exchange-based Health Plan – Access to your provider is through a single insurance carrier that has its network of providers (physicians and hospitals) who have contracted with Covered California to provide their services. All other providers not through this Covered California insurance carrier are out of network providers and are not covered under this Exchange-based health plan. Make sure your doctor/hospital recognizes the Exchange-Based Plan as a carrier they will do business with.
* Subsidy or premium assistance – available to those persons based on size of family and limit of income (generally between $44,680 to $92,200 for the year 2014 only) which is between 138% to 400% of the Federal Poverty Level (FPL).
* Metal Tier Benefit Level- Benefits are divided in to different categories or tiers of benefits. There are at total of four (4) levels,”Bronze”,”Silver”,”Gold” and “Platinum”. The basic benefit plan is the “Bronze”, with the highest benefit plan being “Platinum”. Costs, deductibles, Maximum out of pocket expenses for each level increases/changes as you progress from Bronze to Platinum.
* Network of Medical Care Plans- There are basically four types of network plans you must become familiar with in order to understand your Health and Medical information options. These are EPO, HMO, PPO and HSA Plans.
* EPO – Exclusive Provider Organization health insurance plan is a managed care system. It is a group of providers which provide services to those who purchase the insurer’s policy. The policy holder is required to chose a primary care physician from within the EPO network. Generally, EPOs are very efficient but have limited network doctors. No out of network referrals are allowed.
* PPO – Preferred Provider Organization is similar to an EPO, however, policy holders of PPOs can avail themselves to services from providers other than the designated providers. Thus these are generally thought to be larger groups of providers, however, reimbursement rates will not be as comprehensive due to deductible, co-pays, lower reimbursements percentages etc.
* HMO – Health Maintenance Organization is a plan where the entire payment is covered. HMO providers are compensated on a monthly rate based on the number of policy holders signed up to their service. Monthly payments are made regardless of utilization by policy holder. No out of network service is reimbursable. Limited to those physicians that are participating in that HMO.
* HSA – Health Savings Account plans are those that offer tax deductiblity and savings. There are very specific restrictions as to their use and description. Please research these separately from this forum. I am not a tax person and do not offer tax advise.
There are significant other topics that you need to make sure you are fully aware of, prior to finalizing any health and medical decision. Not discussed are the impact of Medi-Cal benefits to the low or modest income family. Process of securing the correct coverage and working with the insurance carrier, under new constraints in costumer service, internet based processing and working through the quagmire of 800 phone # options and selection choices.
If you are interested in any follow up discussions, please feel free to contact me. I am happy to share what is proving to be a learning experience for all health care specialist.