There are two parts to this question. The first answer on coverage – is yes. The state of Connecticut has more mandates on the kinds of treatments, which have to be covered, than most states. If I recall we are the 5th highest in the US. This means whether a person enrolls in a plan in the Individual or Small Group market the kinds of medical treatment coverage will be extensive.
The second part of the question on coverage is – will people who enroll have to pay co-pays and cost sharing? The answer is Yes. For many reasons much of the cost of medical insurance in Conn is connected to the cost of medical treatment. Small group medical insurance plans for example are some of the most expensive in the US. Thus, the only way to control the cost of premiums is to include individual cost sharing in the plan design.
Federal health reform requires Individual and Small Group market plans in the current market, which I am calling “outside” and plans in Connecticut’s Health Insurance Marketplace, which is marketing under the name Access Health CT to meet certain coverage requirements.
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● The first – plans must include what the law calls Essential Health Benefits (EHB) and there are 10. Two of them, which are not currently in plans in Conn, are pediatric dental coverage (for age 19 and under) and what is called habilitative services. Plans today cover the rehabilitative services an individual needs to recuperate for example following hip surgery but coverage stops when the person is no longer improving. Habilitative coverage is for those who are no longer improving but their condition can fall back if the services were to stop.
● Health reform also introduced a complex calculation to review the plan’s design and determine how much the health insurance company has to pay and how much an individual will pay. This calculation determines what reform calls the plans Actuarial Value. As part of this plans are divided into four levels. They are Platinum, Gold, Silver, and Bronze.
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● Some additional information about the four “metal” level plans.
+ Platinum has to cover 90% of the required EHBs. Gold is 80%, Silver is 70%, and Bronze is 60%.
+ When looking, for example, at a Silver plan a person might think – oh my if I have $100,000 in medical expenses I will have to pay $30,000. The answer is NO. The percent of coverage a person pays only applies to initial treatment and their expenses are limited by the plans maximum out of pocket (MOP) provision. This limit will be adjusted each year and is set in the health reform law to follow the maximum expense provisions of health savings account plans. During 2013 the MOP for Single coverage is $6,250.
Lets look at the Silver plan. Regulations say premium support will be based on the Silver plan from the company which has the second lowest premium. Here in Connecticut Single coverage under the Silver plan in Access Health CT will have:
+ A $3,000 deductible on medical treatment
+ A $400 deductible on prescription coverage
+ A $30 co-pay for a primary care doctor visit and $45 to see a specialist
+ A $150 co-pay for an emergency room visit
+ A $500 per day for hospitalization, after the medical deductible has been met
+ A maximum out of pocket (MOP) of $6,250 for Single coverage.
When a Single person’s income is at 400% of the federal poverty level (FPL) or lower the MOP is reduced. It drops in three steps for lower income. When income is at 250% of FPL the plans co-pays and cost sharing are also reduced.
