What’s New in Small Business Health Options Program (SHOP)?

Covered California has released the list of Health Insurance Companies that will participate in (SHOP).  Six players will provide HMO and PPO plans.  Premiums appears to be close to the 2013 rates.  If your company qualifies for discounts those will only be available by participation in (SHOP)

For more information please see http://www.californiahealthline.org/articles/2013/8/2/covered-california-posts-details-premium-rates-for-shop-plans.

Understanding the Affordable Care Act (ACA)

The way Americans receive health care will be changing starting in 2014.  With individual “Open Enrollment” just around the corner (October 1st  - December 15th) much confusion still exists.  The Kaiser Family Foundation released a new animated video to help people understand the health care system changes on the horizon.  “The You Toons Get Ready for Obamacare” explains the basic changes in the way American will get health coverage.  For help in navigating the new system and for questions regarding help with federal tax credits, contact your health professional


New Health Exchanges May Mean Fewer Choices

Nearly half of all proposed health insurance exchange plans examined in a McKinsey & Co. analysis were health-maintenance organization (HMOs) or similar plans, and many others have networks that limit the choices of doctors and hospitals.  That could force some people to choose between switching doctors or paying out of pocket.

The Wall Street Journal (tiered subscription model) (8/14)

Choosing the right Medicare Plan


How do you choose the Medicare Plan that is right for you?  Let’s start by reviewing the different Medicare options available for Fresno area residents:

 1. Medicare Only  - With Medicare Part A and part B alone you have coverage, which includes “Medically Necessary” care and some preventive care. After applicable deductibles you would pay 20% of cost.  However, there is no “Out of Pocket” cap (for example: if the cost is $400,000 you could be responsibility for as much as 20% or $80,000). While Medicare alone covers the bulk of your regular medical expenses it still leaves gaps and does not cover Prescriptions.  If you use a physician who does not accept Medicare assignment as payment in full you could be personally responsible for additional charges up to 15%.

 2. Medicare part A&B with a Supplement Plan (Gap Plan) and Prescription D Plan – The supplement plan covers gaps left by the original Medicare A&B.  This plan usually covers the deductibles and most of the out of pocket cost not covered by Medicare alone (the coverage varies based on the supplement plan chosen).  A standalone prescription D plan should be chosen to cover prescription costs.  While there are special enrollment periods for “guaranteed issue”, application can be made at any time, but may be subject to underwriting if outside the enrollment periods.  Enrollment in plan D requires application with in specific enrollment periods. 

3. Advantage C Plans with Prescription Drug Coverage – These plans usually have the lowest premiums but carry additional out of pocket risk. There may or may not be deductibles, co-pays for certain services, and a share of cost for others.  Each plan will have a maximum annual out of pocket (OOP) cost protection.  Once the annual OOP is met the plan benefits will continue for the rest of that calendar year.    

 Enrollment in an Advantage Plan is limited to specific enrollment periods.  The annual enrollment period (AEP) is October 15th through November 30th for an effective date of January 1st.  Call us to see if you qualify for a Special Enrollment Period (SEP).

 4. Prescription D Plans – The cost for drugs is usually a co-pay, based on the category of the drug.  The formulary is a list of drugs the specific plan offers.  Formularies differ from carrier to carrier.  To find which carrier can provide your drugs, at the lowest cost, you may want to check your drugs against the formularies from different carriers. 

 Summary – The right plan for you depends on a number of factors.  Many of these are personal preferences such as, how important is the ability to to choose you own doctor or specialist, how must risk you wish to carry, and the amount a monthly premium you want to pay.  Other factors include, will you be in and out of your local service area during the year, your personal health, and use of prescription drugs.

 As Senior Heath Specialist, we are here to assist you.  If you have questions give us a call at 559-298-8804, or use the “Contact Us” page on the website

 Fresnohealthplans.com  by Jay