What kind of coverage will the plans coming in January provide?

There are two parts to answering this question. First - medical treatment coverage. The state of Connecticut has more mandates on treatments, which have to be covered, than most states. If I recall we are the 5th highest in the US. Thus, since the kinds of medical treatment currently required to be covered is extensive, the first answer – is yes plus more in January.

Second – will people have a lot of co-pays and cost sharing? This answer is also Yes. Why: For many reasons much of the cost of medical insurance in Conn comes from ever growing medical treatment expenses. Because of these big expenses and other reasons, the only way to control the cost of premiums is for individuals to have co-pays and cost sharing.

A look at the new plans: Federal health reform requires, starting in January, medical insurance plans to meet certain coverage requirements.

● The first – plans must include what the law calls Essential Health Benefits (EHB) and there are 10. Most are now in Connecticut’s mandates. Two, which are not, are pediatric dental coverage (for age 19 and under) and what is called Habilitative services. The rehabilitative services an individual needs for example to recuperate following hip surgery are covered. Coverage however, stops when the person stops improving. The new Habilitative coverage is for certain coditions when someone is no longer improving and could fall back if the services were to stop.

●  Health reform coverage requirements also include a complex calculation of the plan’s design to determine how much the health insurance company has to pay and how much an individual will pay. This calculation determines what is called the plans Actuarial Value. This requirement also divides plans into four levels -  Platinum, Gold, Silver, and Bronze.

● Some additional information on what are often called the “metal” level plans:

 + Platinum – the company has to cover 90% of the required EHBs and the individual 10%. Gold is 80% by the company, Silver is 70%, and Bronze is 60%.

 + The percent of coverage a person pays only applies to initial treatment since their expenses are limited by the plans maximum out of pocket (MOP) provision. Thus, a person in a Silver plan who has $100,000 in medical expenses will not have to pay $30,000 because of the MOP provision. The MOP limit will be adjusted each year following the maximum expense provisions of health savings account plans. During 2013 the MOP for Single coverage is $6,250.

Lets look at Connecticut’s Silver plan. It will have:

+ 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 $400 deductible on prescription coverage

+ A $3,000 deductible on various kinds of medical treatment

+ 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.

The regulations implementing these coverage related changes apply to Individual and Small Group plans in what I call the “outside” market and to plans available through the Connecticut’s Health Insurance Marketplace, which is using the name Access Health CT.

   Note: No medical insurance company is planning to offer a Platinum plan in Conn.

Reform regulations also tell us premium support will be available to individuals, through Access Health CT, whose income is at 400% of FPL. It is designed to help them with the monthly cost of their premium and will be calculated using the premium for the second lowest cost Silver plan. Individuals at 250% of FPL or below will be enrolled in a Silver plan with reduced co-pays and cost sharing.

Want to take a look at whether you would be eligible for help through a premium discount and what your share might be? Go to AccessHealthCT.com. There is a link to a savings calculator on the home page.

John C Parker, RHU, LTCP

Niantic CT