Proposed health care plans laid out, down to the copays
By David Taube
Vermont Press Bureau | August 22,2012
MONTPELIER — Making private health insurance plans in the state look more like personalized auto insurance policies, complete with a website to compare options, gained some eye-catching momentum Tuesday.
State officials unveiled what kinds of costs and health plan designs consumers could expect on the health benefits “exchange,” pending public input and Green Mountain Care Board approval.
State officials expect to launch the exchange in October 2013.
Using federally set parameters, state officials have proposed requirements for insurance companies on what consumers would pay for aspects of a plan, covering everything from the cost of generic prescriptions and specialist office visits to proposing deductible thresholds.
Medical deductibles — the amount a consumer has to pay out of pocket each year before the insurance kicks in — could be $250, $750, $1,750, $1,900 or $2,000, depending on the plan. Prescription deductibles could be anywhere from zero to $1,250.
Copays for generic prescriptions could be $5 or $10, regardless of the plan. Urgent care could have $40 or $50 copays for higher-level plans and $50, $20, $100 or 50 percent for lower-level plans.
At least one comment period with the Green Mountain Care Board is expected. In addition to the six plans the state will specify for the exchange, the state is giving insurance companies the option to create three alternatives.
Those alternative designs — which also have to meet certain federal parameters — will be discussed Sept. 6.
The health benefits exchange will allow consumers to compare plans that have similar metrics, unlike Utah's exchange where the state basically just created a website for insurance companies to submit plans, said Vermont's director of health care reform, Robin Lunge.
Four levels set by the federal Affordable Care Act will require insurers to pay a fixed percentage of health care costs for exchange plans, then consumers pay the remaining percentage through various deductibles, copays and coinsurance.
An insurance company will pay 90 percent under the platinum plan, 80 percent under the gold plan, 70 percent on the silver plan and 60 percent on the bronze plan.
While the federal government has projected a $6,250 cap in health benefits exchanges for out-of-pocket expenses — which includes deductibles, copays and coinsurance but not premiums — plans proposed Tuesday by state officials have various thresholds.
Out-of-pocket maximums for medical expenses under the platinum plan would be $1,250 and $4,250 for the gold plan, pending the board's approval.
Under the proposal, silver and bronze plans specified by the state would allow various overlaps between prescription and medical out-of-pocket maximums and deductibles. So in one bronze plan, when customers meet their $1,250 out-of-pocket maximum in prescriptions, that amount counts toward the $6,250 medical out-of-pocket maximum.
Lunge said Tuesday that all of the plans cap out-of-pocket costs for prescriptions at $1,250, part of a state law enacted this year, which will also apply to health plans that renew this year even outside of the exchange.
Health insurance companies in the exchange will set the cost of premiums.
Small businesses, the uninsured, legal immigrants and those with individual plans will be able to participate in the initial phase of the exchange, according to the Vermont Campaign for Health Care Security Education Fund.
The six exchange plans proposed by the state are as follows, and all details are pending approval by the Green Mountain Care Board:
This plan features a moderate deductible with a small out-of-pocket maximum, similar to the most popular state employee plan, according to the state.
Key details: medical deductible of $250, prescription deductible of zero; waived preventive, office visit, urgent care, ambulance and emergency room fees.
Out-of-pocket maximum for medical expenses is $1,250.
Inpatient, outpatient, radiology costs are 10 percent for customers, $100 emergency room copays, $10 office visits, a $20 copay for specialist office visits, $40 copays for urgent care, $50 copays for ambulance services.
Prescription copays of $5 for generics, $40 for preferred brands and 50 percent for nonpreferred brands.
This plan has a mid-range deductible similar to the Catamount Health design, according to the state.
Key details: medical deductible of $750 and $50 for prescriptions.
The plan also proposes a $4,250 medical out-of-pocket maximum.
Waived deductibles for preventive, office visit, urgent care, ambulance and emergency room services as well as generic prescriptions.
Inpatient, outpatient and radiology costs would be 20 percent. Emergency room visits would require a $150 copay, office visits $15 copays and $25 for specialists, urgent care services a $45 copay, $50 for ambulance services.
Prescription copays would be $5 for generics, $40 for preferred brands and 50 percent for nonpreferred brands.
Silver plan specified design one
This plan focuses on copays rather than coinsurance.
Key details: medical deductible of $1,900 and prescription deductible of $100.
Out-of-pocket maximum medical expenses would be $5,000.
Paying into the medical deductible would be waived for preventive, office visit, urgent care, ambulance and ER services as well as generic prescriptions.
Copays would be $250 for the emergency room, $20 for office visits, $30 for specialists, $50 for urgent care and $100 for ambulance services. Coinsurance would be 40 percent for inpatient and outpatient services as well as radiology tests like MRIs and CT scans.
Prescription costs would be $10 copays for generic drugs, $50 for preferred brands and 50 percent coinsurance for nonpreferred brands.
Silver plan specified design two
This high-deductible health plan focuses on coinsurance rather than copays.
Key details: medical deductible of $1,750 and prescription deductible of $1,250.
A proposed $6,250 out-of-pocket maximum for medical expenses.
Waived costs include preventive measures and wellness prescriptions.
Coinsurance costs would be 20 percent for inpatient and outpatient services as well as ER and radiology, office visits, specialist office visits and ambulance services. Urgent care would require a $20 copay.
The copay would be $10 for generic prescriptions and $50 for preferred brands. Nonpreferred brands would have a 50 percent coinsurance cost.
Bronze plan specified design one
Like the first state-defined option of the silver plan, this plan makes more use of copays instead of coinsurance.
Key details: a $1,900 medical deductible and $100 for prescriptions.
Out-of-pocket maximum expenses would be $6,250.
Medical expenses for preventive care are waived, and there's no cost for prescriptions of all types.
Copays would be $35 for office visits, $80 for specialists, $100 for urgent care and ambulance services, and $350 for the emergency room.
Coinsurance costs would be 50 percent for inpatient, outpatient and radiology.
Prescription costs would be a $10 copay for generic drugs, 40 percent coinsurance cost for preferred brands and 60 percent coinsurance for nonpreferred brands.
Bronze plan specified design two
Coinsurance costs are more likely in this plan.
Key details: a $2,000 medical deductible and $1,250 prescription deductible.
The out-of-pocket maximum for medical expenses would be $6,250.
Deductible costs are waived for preventive and wellness prescriptions.
Coinsurance would be 50 percent for most services, including inpatient, outpatient and radiology tests, the ER, office visits and specialists, urgent care and ambulance services.
Prescriptions would have a $10 copay for generic brands, 40 percent coinsurance for preferred brands and 60 percent coinsurance for nonpreferred brands.