Uncertainty Ends: Here’s What Your Group Insurance Through Covered California Will Cost

By
Greg Diamond
– September 15, 2013Posted in: "The OC", Fresh Juice

We’ve been arguing for months (or is it years?) about what health insurance through the Covered California exchange — our local flavor of Obamacare — will cost.  Now we know.  It’s at the link just below.

http://www.coveredca.com/fieldcalc/#calculator

Obamacare essentially eliminates most of that highly lousy individual insurance we’ve enjoyed for years and replaces it with group insurance — and the discounts obtained from it — by putting almost all of the otherwise uninsured into a group.  (That’s in addition to all of the consumer protection provisions — ending rescission and pre-existing condition exclusions and annual and lifetime limits and more — that liberals love and conservatives are generally afraid to criticize out loud.)  The argument has been made here — loudly and often — that this insurance will be too expensive for people to afford.

Well, using this calculator, now we can discuss this in concrete terms.  All are in OC Region 18.  Meet me below the photo of a smiling and triumphant Health and Human Services Secretary Kathleen Sebelius.

Kathleen Sebelius

You cannot stop Kathleen Sebelius when she wants to implement Obamacare. You might as well not even try.

Example 1: Married couple, 32 and 29, with 3 kids making $50,100/year, in Santa Ana

OK, you can see the assumptions I’m making above.  Let’s see what their insurance will cost.    Here’s what it says:

Metal Tiers: Enhanced Silver 87, and Bronze

The two options displayed below detail the options that are the lowest cost and best value for you. You can compare the benefits provided at each plan level or “metal tier.”

The two best options for you are the Enhanced Silver 87 or the Bronze plans.

  • Due to your income level, you qualify for the Enhanced Silver 87 plans, which provide assistance with out-of-pocket costs in addition to premium assistance. Enhanced Silver 87 plans will cover an average of 87% of costs, meaning that, on average, you will be responsible for 13% of your health care costs. Most common covered services under the Enhanced Silver Plan do not have a deductible.
  • You could also select a Bronze plan. Bronze plans cover an average of 60% of costs, meaning that, on average, you will be responsible for paying 40% of your health care costs. Also, most services covered by the Bronze plan are subject to a deductible, or amount you must pay out-of-pocket before the plan will cover costs.

You can compare the charts below to see what your costs would be under each plan. It is important to understand the benefits and risks, and determine how much health care you expect to use. While the Bronze plan has the cheapest monthly premium, the Enhanced Silver Plan provides a lower risk of out-of-pocket costs, making it a better value for most people.

STANDARD BENEFITS FOR INDIVIDUALS

Key benefits
Bronze 60 (italics) and Enhanced Silver 87 (underlined)
(You’ll need to see the chart to see what’s subject to the deductible: most of bronze and little of silver)
Maximum Deductible
$5000 deductible for medical & drugs
$500 medical deductible +$50 brand drug deductible
Preventative Care Copay1
no cost — at least 1 yearly visit
no cost
Primary Care Visit Copay
$60 — 3 visits per year vs. $15
Specialty Care Visit Copay
$70 vs. $20
Urgent Care Visit Copay
$120 vs. $30
General Medication Copay
$19 vs. $5
Lab Testing Copay
30% vs. $15
X-Ray Copay
30% vs $20
Emergency Room Copay
$300 vs. $75
High cost and infrequent services (e.g. Hospital Care and Outpatient Surgery)
30% of your plan’s negotiated rate vs. 15%
Preferred brand copay after Drug Deductible (if any)
$50 vs. $15
Maximum Out-of-Pocket For One
$6,350 vs. $2,250
Maximum Out-of-Pocket For Family
$12,700 vs. $4,500
1 in-network only

This family will be subsidized $292/month (a tax credit) for their health insurance.

Anthem Blue Cross is offering two Bronze plans, one that will cost this family $100/month and one $103/mo. HealthNet has a Bronze plan for $132/mo; Blue Shield for $137/mo.

HealthNet’s Silver plan is $166/month.  Anthem Blue Cross has one for $228 and one for $232 and Blue Shield’s is $236.

Let’s try another one.

Example 2: Married couple, 58 and 57, with 0 kids, making $150,100/year, in Newport Beach

Here’s what it spits out for them.

Metal Tiers: Platinum, Gold, Silver, and Bronze

You do not qualify for premium assistance through Covered California. However, you may still purchase a high quality health insurance plan that fits your needs. Each private health insurance plan sold through Covered California offers four different levels of coverage. These levels, or “metal tiers,” are called platinum, gold, silver, and bronze.

Platinum plans have the highest premium, yet pay 90% of covered health care expenses. Bronze plans have the lowest premium, but pay only 60% of covered health expenses. It’s important to think about how much health care you will need when choosing a level. The charts below show how much you will pay for covered services under each level of plan.

STANDARD BENEFITS FOR INDIVIDUALS

Key benefits
Bronze 60, Silver 70 (Lower Cost Sharing Available on Sliding Scale), Gold 80, Platinum 90
Deductible
$5000 deductible for medical & drugs / $2000 medical deductible / no deductible / no deductible
Preventative Care Copay1
no cost at least 1 yearly visit for all
Primary Care Visit Copay
$60 for 3 visits per year / $45 / $30 / $20
Specialty Care Visit Copay
$70 / $65 / $50 / $40
Urgent Care Visit Copay
$120 / $60 / $90 / $40
General Medication Copay
$19 / $19 / $19 / $5
Lab Testing Copay
30% / $45 / $30 / $20
X-Ray Copay
30% / $65 / $50 / $40
Emergency Room Copay
$300 / $250 / $250 / $150
High cost and infrequent services (e.g. Hospital Care and Outpatient Surgery)
30%of your plan’s negotiated rate / 20%of your plan’s negotiated rate
HMO Outpatient Surgery – $600, Hospital – $600/day up to 5 days; PPO – 20%
HMO Outpatient Surgery – $250, Hospital – $250/day up to 5 days; PPO – 10%
Imaging (MRI, CT, PET Scans)
30% / $250 / $250 / $150
Brand meds (may be subject to Annual Drug Deductible before you pay copay)
$50 – $75 after meeting deductible / $25 deductible then pay copay amount / no deductible / no deductible
Preferred brand copay after Drug Deductible (if any)
$50 / $50 / $50 / $15
Maximum Out-of-Pocket For One
$6,350 / $6,350 / $6,350 / $4,000
Maximum Out-of-Pocket For Family
$12,700 / $12,700 / $12,700 / $8,000
1 in-network only

This family will not be subsidized for their health insurance.  These next figures may seem high — but compared to the pre-Obamacare cost of non-group health insurance (leaving aside pre-existing conditions and the like) for a couple this age, they aren’t.  For whatever reason, Kaiser HMO doesn’t seem to be available to them.  (To find Kaiser, you have to notice that there are two dots on the bottom of the list of plans and realize that you have to click on the second one.  Bad page design there!)

The  Bronze PPO plans would cost this family between $848 and $929 per month, or $945-960 for Kaiser HMO.

The Silver PPO plans would cost this family between $992 and $1143 per month, or $1306 for Kaiser.

The Gold PPO plans would cost this family between $1142 and $1408 per month, or $1588 for Kaiser.

The Platinum PPO plans would cost this family between $1266 and $1609 per month, or $1708 for Kaiser.

If any older couples in this (or a similar) income range want to share how much they’re currently paying for non-group insurance, I’d be interested in knowing.

Example 3: Single, 27, 0 kids, making $35,100/year, in Placentia

STANDARD BENEFITS FOR INDIVIDUALS

Key benefits
Bronze 60, Silver 70 (Lower Cost Sharing Available on Sliding Scale), Gold 80, Platinum 90
Deductible
$5000 deductible for medical & drugs / $2000 medical deductible / no deductible / no deductible
Preventative Care Copay1
no cost at least 1 yearly visit for all
Primary Care Visit Copay
$60 for 3 visits per year / $45 / $30 / $20
Specialty Care Visit Copay
$70 / $65 / $50 / $40
Urgent Care Visit Copay
$120 / $60 / $90 / $40
General Medication Copay
$19 / $19 / $19 / $5
Lab Testing Copay
30% / $45 / $30 / $20
X-Ray Copay
30% / $65 / $50 / $40
Emergency Room Copay
$300 / $250 / $250 / $150
High cost and infrequent services (e.g. Hospital Care and Outpatient Surgery)
30%of your plan’s negotiated rate / 20%of your plan’s negotiated rate
HMO Outpatient Surgery – $600, Hospital – $600/day up to 5 days; PPO – 20%
HMO Outpatient Surgery – $250, Hospital – $250/day up to 5 days; PPO – 10%
Imaging (MRI, CT, PET Scans)
30% / $250 / $250 / $150
Brand meds (may be subject to Annual Drug Deductible before you pay copay)
$50 – $75 after meeting deductible / $25 deductible then pay copay amount / no deductible / no deductible
Preferred brand copay after Drug Deductible (if any)
$50 / $50 / $50 / $15
Maximum Out-of-Pocket For One
$6,350 / $6,350 / $6,350 / $4,000
Maximum Out-of-Pocket For Family
$12,700 / $12,700 / $12,700 / $8,000
1 in-network only

The  Bronze PPO plans would cost this individual between $178 and $198 per month, or $202-205 for Kaiser HMO.

The Silver PPO plans would cost this individual between $209 and $240 per month, or $275 for Kaiser.

The Gold PPO plans would cost this individual between $236 and $298 per month, with $335 for Kaiser, though Kaiser and the most expensive plan are “grayed out” for some unexplained reason.

The Platinum PPO plans would cost this individual $266  per month for HealthNet, between $324 and $338 for three “grayed out” plans, and $359 for Kaiser.  (Maybe the grayed-out plans are just worse deals?)

So, at the low level, about $3000 per month gross income, for a Silver plan $200 goes to insurance.  This is without subsidies; for someone making less income, it would be less.

Any other calculations you’d like to add for yourselves?

A Final Note:

This is what you get when you want to work through private insurers, without cost competition from a public option.  A single-payer plan would probably be cheaper and easier in the long-run, but then people wouldn’t be as desperate!  (Can’t have that!)

About Greg Diamond

Somewhat verbose attorney, semi-disabled and semi-retired, residing in northwest Brea. Occasionally ran for office against jerks who otherwise would have gonr unopposed. Got 45% of the vote against Bob Huff for State Senate in 2012; Josh Newman then won the seat in 2016. In 2014 became the first attorney to challenge OCDA Tony Rackauckas since 2002; Todd Spitzer then won that seat in 2018. Every time he's run against some rotten incumbent, the *next* person to challenge them wins! He's OK with that. Corrupt party hacks hate him. He's OK with that too. He does advise some local campaigns informally and (so far) without compensation. (If that last bit changes, he will declare the interest.) His daughter is a professional campaign treasurer. He doesn't usually know whom she and her firm represent. Whether they do so never influences his endorsements or coverage. (He does have his own strong opinions.) But when he does check campaign finance forms, he is often happily surprised to learn that good candidates he respects often DO hire her firm. (Maybe bad ones are scared off by his relationship with her, but they needn't be.)