Skip to main content

The California Individual Health Market Under PPACA (2014)

There seems to be quite a bit of confusion out there as regards the upcoming healthcare reform market for individuals and families in California.

There will be one pool of people in the overall market comprising one single risk pool.  In that overall single pool there will be two markets available for individuals and families in California to purchase qualifying health plans (QHP) which have not yet been developed by the carriers for the markets (deadline for the exchange is May 31, 2013).  QHPs must fall into a 'precious metals' tier of Platinum, Gold, Silver, Bronze and one Catastrophic Tier.  They must meet actuarial values  as determined by the PPACA.

The Exchange

California will operate a state health benefits exchange which will offer plans inside of the exchange to those who wish to purchase those plans and especially for those seeking premium subsidy assistance or credit (or both).  Subsidy for exchange plans will be based on financial qualification and will be set to the Silver Tier of plans.  Anyone seeking a subsidy MUST purchase their health insurance through the exchange to receive that subsidy.  Subsidy will not be available to those who purchase outside of the exchange who otherwise would qualify.

Insurance carriers will offer certain plans to the exchange and these plans will need to conform to exchange requirements.  They may offer plans at every tier level or only at certain tier levels. Some insurance carriers may not offer any plans to the exchange. 

Outside The Exchange (Copycats)

Insurance carriers must duplicate the plans they offer inside of the health benefits exchange outside of the exchange.  If a carrier offers four silver plans and one bronze plan inside of the exchange, that carrier must also offer the exact same plans outside of the exchange.

Outside The Exchange Only 

In addition to the copycat plans mirroring the exchange plans, insurance carriers can and will create other plans to be specifically sold only outside of the exchange.  These plans will also be guaranteed-issue and will not be available inside of the exchange for subsidy qualifiers or those wishing to purchase exchange level coverage.

Plans sold only outside of the exchange must meet a 'metal tier', have the correct actuarial value, and contain the required 'essential health benefits'.  Beyond that, carriers can and likely will create broader plans for this market segment with different provider networks (think larger), different plan options (HSAs), different co-pays, Rx benefits, drug formulary and so on.  

These plans will likely represent the primary coverage plan purchases by those who do not qualify for subsidy from the exchange.  

I will add a blog soon with information on general income guidance for subsidy qualification from the health benefits exchange.

Brokers and agents will be permitted to assist with enrollments inside or outside of the exchange with commission compensation (still unknown) to be paid by the insurance carriers directly.  Exchange enrollments will need to be done through the exchange portal or by paper application from the exchange.  Plans sold outside of the exchange will be carrier specific pretty much like it is now.

Dave
www.davefluker.com

Comments

Popular posts from this blog

Anthem Blue Cross (CA) Adding SilverSneakers® Fitness Program

Anthem Blue Cross (CA) announced this morning that they will be adding the SilverSneakers Fitness Program to California Medicare Supplement Plans A, F, and N.  The added benefit will begin on January 1st, 2017. 

Once approved for release into the market, more states have been added to the list as existing and new members in our marketed plans will enjoy the value-added benefits of the SilverSneakers Fitness program at no additional cost! Effective January 1, 2017, California members in our marketed plans will enjoy SilverSneakers, too.  The program offers members their choice of paths to better health. For those who enjoy a traditional workout setting, SilverSneakers offers access to more than 13,000 fitness locations across the country, including use of classes and guidance from a Program AdvisorTM. In addition, for those who can’t get to a fitness center, SilverSneakers Steps® kits focus on at-home or on-the-go general fitness, walking, strength training or yoga. And if that is not …

How Will Donald TRUMP ObamaCare?

With the election of Donald Trump as the next US President, healthcare reform and ObamaCare are on the chopping block.  There is media speculation that a transformation away from the current ObamaCare system will be rather immediate once Donald Trump is sworn into office in January.  


While changes are certainly coming, I would not expect a wholesale changeover immediately, but rather over the course of 2017.  My hope is to see an open market available at any time during the year (like it used to be) instead of an abbreviated Open Enrollment Period.  

Below are some key points to a Donald Trump-Care system and a link to his Healthcare Reform Paper which goes into more detail...



 1. Completely repeal Obamacare. 2. Modify existing law that inhibits the sale of health insurance across state lines. 3. Allow individuals to fully deduct health insurance premium payments 4. Allow individuals to use Health Savings Accounts (HSAs). 5. Require price transparency from all healthcare providers.6. Bl…

2016 Open Enrollment Has Begun

Here to kickoff the 2016 open enrollment period which will run from November 1, 2015 to January 31, 2016.  

It is important to remember that during the open enrollment period all rules regarding SEP (special election period) enrollment dates for loss of employer coverage are off of the tablle. Than means no retroactive start dates on the Covered California health exchange.

Remember during open enrollment you may sign up for any available health insurance plan either off- or on-exchange with no medical underwriting.

My site features live free instant quotes and online applications for off-exchange subscribers.

For Covered California exchange subscribers, I can take your information over the phone and set up your account on Covered CA for you.  You would need to log in with a special code I would provide upon submission of the application and select your plan/pay the initial premium via Covered CA.  

Carrier for 2016 include:

*Anthem Blue Cross PPO, Tiered PPO and HMO
*Blue Shield of Californi…