The process of buying health insurance in Ohio has changed. Policy benefits are different, rates are no longer the same, medical questions are no longer asked, and individual and family federal subsidies can reduce the premium you pay. We will always provide the lowest prices, and you are now further helped by federal assistance. However, you can also choose policies that receive no federal or state financial aid (Marketplace, CHIP, or Medicaid).
Senior Medigap plans are not impacted since Supplement and Advantage plans are designed to cover persons that have reached age 65 or are eligible for Medicare. Part D prescription drug plans are offered separately, and are often used in conjunction with MA plans without drug benefits.
But perhaps the biggest difference is the introduction of “Metal” plans several years ago. There are four healthcare categories comprised of “Platinum,” “Gold,” “Silver” and “Bronze” policies. The principal differences in plan coverage are related to the percentage of costs paid for essential health benefits, which, by law, must be included on all four medal contracts through the Ohio Health Exchange.
There is also a separate “catastrophic” category that features the cheapest available plans. However, there are enrollment requirements including qualifying for special “financial hardship” status. Some of the requirements include being homeless, a victim of domestic violence, death of an immediate family member and a bankruptcy within the last six months. NOTE: Any applicant under age 30 automatically qualifies for a catastrophic policy. However, often, a Bronze-tier contract is a better option, since premiums may be lower, and deductibles may not apply to as many items. Many more policies are also offered.
Some of the required benefits of all Metal plans include:
Prescriptions: Both generic and non-generic must be included.
Hospitalization: Major and minor necessary procedures. Of course, physician fees, anesthesia etc…also covered.
Substance Use & Abuse: Many different types of counseling and treatment are offered.
Preventative Services: In addition to annual physicals and OBGYN exams, management of chronic diseases is covered.
Maternity: Tests and procedures leading up to the birth of the child along with newborn coverage that is effective immediately.
Pediatric: In addition to wellness, some dental and vision also included.
Mental Health: Both inpatient and outpatient including counseling.
X-Rays, Lab Tests & Diagnostic Services.
Rehab Treatment & Services: There are many items that are covered including learning how to talk or walk after a stroke, usage of limb functions, return of usage of basic motor skills and many speech-related items.
Ambulance: Usage of an ambulance when needed.
Ohio (like any other state) can add additional benefits to the list of required ones. However, each state can choose completely different coverage to add. Thus, it is possible that if you move to or from a state, you may not be able to keep the same policy. However, your acceptance when applying for new benefits is guaranteed in advance. NOTE: Although Ohio has a robust number of available carriers, many other states have counties that offer just one or two choices. In future years, additional Buckeye State companies may be offering coverage.
Explanation Of Four Metal Plans
The actuarial value is the percentage of the total average expenses that the medical plans pays throughout the calendar year. The value is determined by insurers, and includes deductibles, copays, coinsurance, and other out-of-pocket expenses. The expected percentage of your expenses that each of the four options will pay are listed below:
Platinum – 90% (You pay 10%)
Gold – 80% (You pay 20%)
Silver – 70% (You pay 30%)
Bronze – 60% (You pay 40%)
Bronze plans are the cheapest option since your out-of-pocket expenses are the most. Approximately $8,150 ($16,300 for a family) is the expected maximum you would pay in a worst-case scenario. This type of coverage may be ideal for high-income individuals or families that are relatively healthy and want a low premium. Specialist visits and brand name drugs may be subject to a deductible. If affordability is an issue and/or you are on a tight budget, a Bronze policy should be considered. “Cost-sharing” is not available.
Silver plans must be offered by any company that chooses to participate on the Ohio Health Insurance Exchange. They also must offer a Gold plan (see below). However, they do not have to offer either of the other two policies. This option is the second-cheapest policy offered, and typically features plans with moderate premiums and lower deductibles than the Bronze tier.
Special “cost sharing reduction” contracts (CSR) are available with lower costs (if you can qualify with your income). Silver contracts are often referred to as “Benchmark” plans since your federal subsidy calculations are often calculated using this specific option. Often, office visits to specialists are covered with a copay, instead of having to meet a deductible. Urgent Care visits are also often covered without having to meet a deductible. Preferred non-generic prescriptions are often available with a mail-order discount.
Gold plans are the second most comprehensive (and expensive) option. They are considered 80/20, meaning approximately 80% of the average anticipated medical expenses will be covered by this policy. Until Metal policies were created, 80/20 was the most common coinsurance on group and individual coverage. Many employer-provided plans are modeled after Gold-tier plans.
Because of the cost, most applicants that do not qualify for federal subsidies probably will not select the Gold option. For example, if you need a cheap student health plan in Ohio, you would not want to purchase a Gold policy. Perhaps another type might meet the university or school guidelines. You could also buy a policy that is considered “off-Exchange.”
Platinum plans are the most costly type of coverage that can be purchased. Since 90% of expected expenses are covered, there are not a lot of potential costs for owners of these policies. And it is the only option that allows you to add additional riders. Availability will vary from state to state. Extremely healthy families that only utilize free preventive benefits should not purchase a Platinum plan.
These plans are the least popular policy, since healthy consumers will choose more cost-effective contracts and many unhealthy consumers may not be able to afford this contract, especially without government assistance. Since changes to plans can be made every year (during Open Enrollment), if an expensive chronic medical condition exists, it may be wise to switch to the Platinum plan. And conversely, if major medical conditions are no longer expected, you can consider downgrading benefits to save some money.
NOTE: Although CIGNA does not offer non-business coverage here in Ohio, they do provide a good explanation of Metal plan benefits and their differences. Since premium tax subsidies affect each tier differently, it’s important to recognize the plans that offer the best options. Maximum out-of-pocket expenses are as important as the policy deductible. Although a zero deductible plan appears to be cost-effective, in most situations it is not recommended.
Additional Specific Information:
The cost of the metal policies will be determined by your age, where you live, the insurance company you select, whether you smoke and the size of your family. For example, Anthem Blue Cross premiums are different than Medical Mutual premiums. And of course, a smoker will pay more than a non-smoker. Moving to a neighboring county could easily increase or decrease the rates, and also provide less (or more) policy options.
Previously, it was required (by law) that you buy a policy. The tax the first year was $95 per individual for non-compliance and it had increased every year. The tax has increased to $695 or 2.5% of the household income, whichever was larger. Thus, a husband and wife with income of $60,000 faced a tax of $1,500 if they did not purchase coverage. The higher the income, the more the tax will become. However, last year, legislation removed the mandatory requirement to purchase “qualified” coverage, and the tax penalty was eliminated.
If your individual income is more than $50,000 or your household income is more than $95,000 (assuming a family of four), you may find that policies made available as “Non-Exchange” may be beneficial. Although still offered by major carriers and also containing the required essential health benefits, these policies may be lower in cost and contain much broader participation of doctors and hospitals. And they will still have to meet the same requirements of other Metal plans in the Ohio Health Exchange.
Updates From The Past:
Ohio is one of five states that will get a preview of the new Small-Business Marketplace, also referred to as SHOP. Companies with less than 50 employees are eligible and will be able to review options about three weeks ahead of the scheduled Open Enrollment on November 15th. Businesses with less than 25 employees will also be eligible for a substantial tax credit.
Many companies (as expected) are not offering Platinum or Catastrophic plans, which are the two least-popular Marketplace policies. Silver and Bronze plans are very common choices for both single persons and families.
The maximum allowed deductibles for Marketplace plans have been increased to $8,150 for individual plans, and $16,300 for family plans.
The anticipated phaseout (repeal) of the Affordable Care Act would eliminate Metal tiers. Newer and more customized tiers of benefits would be introduced. We’re still 12-24 months away from the final product, but it will be different!