The California Health Benefit Exchange board is standardizing the co-payment amounts, coinsurance percentages and other plan design features in all new individual and small-group health policies sold in the state.
The federal Patient Protection and Affordable Care Act of 2010 (PPACA) already requires all non-grandfathered, insured individual and small-group plans to cover the services included in a state’s standardized “essential health benefits” (EHB) package starting Jan. 1, 2014.
If PPACA works as drafters expect, insurers will have to sell plans at four “metal levels” — bronze, silver, gold and platinum — based on the percentage of the actuarial value of the EHB package that the plan covers.
The California exchange board — which is calling itself “Covered California” — is going a step further and requiring use of standardized designs.
A chart summarizing the effects of the standardized design approach shows, for example, that a bronze plan could have a $5,000 deductible for medical care and drugs, a silver plan could have a $2,000 deductible, and a gold or platinum plan could not have any deductible.
The co-payment level for a primary care ofice visit could range $25 at a platinum plan to $60 per visit for three visits per year at a bronze plan.
The emergency room co-payment could range from $150 at a platinum plan to $250 per year at a bronze plan.
The maximum out-of-pocket expenses for one insured would range from $4,000 at a platinum plan to $6,400 at a bronze plan.