Covered California for Small Group – SHOP
Did you know that Covered California for Small Group has some of the most competitive rates in California?
Covered California for Small Business rates will never be higher for identical plans offered by the carrier off-exchange or in another exchange. This means, your clients can be assured of the best price when you recommend Covered California.
Health plan types dictate what medical services are available and how they are delivered to you. All health plans deal with networks, basically a group of medical providers. In general, you want to use in-network providers or providers that are in contract with the health plan. So the first thing you should do is verify if the doctors are in the health plan. Why? To keep your costs down. Check also if your preferred hospital is contracted and available to you.
Types of Health Plans
A Health Maintenance Organization (HMO) plan is a plan that requires you to have a Primary Care Physician (PCP). The PCP will be the one who refers you to the specialists. These specialists are typically within the same medical group as the PCP. If the specialists are not in that medical group, then most likely you won’t be able to see them. As for the services and the procedures they have to be arranged first by the doctors and approved by the medical group. This managed care plan essentially reduces the size of the network of providers to only the ones that are contracted with the medical group. This type of plan also demands your patience as time and effort is needed in seeking referral and approval.
A Preferred Provider Organization (PPO) plan on the other hand has much wider network and gives you direct access to the specialists. So if you need to see say your ophthalmologist, you can just dial his number and set an appointment. You can go to both in-network and out-of-network providers. But you want to use in-network providers in most cases. Why? Again, to keep your costs down. Although your PPO plan may pay to out-of-network providers, the amount will only be very little compared to your share.
An Exclusive Provider Organization (EPO) is similar to a PPO in that you don’t need to designate a PCP. You don’t need referrals to see specialists. The main difference between EPO and PPO is that you cannot use out-of-network providers at all. You should stay within the network exclusive to your plan.
A Health care Savings Plan (HSP) is a hybrid between HMO and EPO. It’s like HMO because most HSPs will require you to designate a PCP. It’s like an EPO because you can see specialists without referrals but you can’t go outside the network.
A variation of these types is a Health Savings Account (HSP) health insurance plan. If you have these, you can tax deduct the amount contributed into an HSP account and normally the amount here is used to pay high deductibles and other medical expenses.
Metallic plans
- Bronze-Bronze $5,000 deductible
- Silver-$2,000 deductible
- Gold-$0 deductible
- Platinum-$0 deductible
If you are less than 30 yrs. old, you can also have minimum coverage. Broadly, the differences are in how much the health insurance pays claims, from 60% to 90% of the costs. Minimum coverage plans cover least while Platinum plans cover most. Even if the plans do not cover 100%, one noteworthy fact is that health insurance benefit is unlimited which is especially helpful for people who are in catastrophic circumstances. Another invaluable fact is that you will not have to pay more than $6,600 if you have a minimum coverage plan and $4,000 if you have a Platinum plan — the maximum out-of-pocket cost.
Deductible Selection:
Let me explain by example here how does the deductible, co-pays and co-insurances and out-of-pocket will affect your selection. For example, you have a Standard Silver plan, which has a deductible of $2,000 and co-insurances of 20% for hospitalization. If you have a hospital claim of $30,000, then you pay the first $2,000 for the deductible, then 20% of the balance of $28,000 or the equivalent of $5,600. The total should be $7,600. But since it’s more than $6,250 which is your out-of-pocket max, the maximum you need to pay is limited to $6,250. The idea is the more services you need or the less deductible, co-pays or co-insurances you want, you would select the more expensive metallic plan.
If your meds are expensive, you won’t like minimum coverage nor Bronze because the deductible includes the drug deductible, which means that health insurance will not help you on meds until you go beyond the overall deductible. In the case of Standard Silver on the other hand, the brand name drug deductible is carved out, $250 to be exact.
If you are offered Enhanced Silver plan by Covered CA based on income, you may opt for that because the deductible, co-pays, co-insurances and out-of-pocket may also be subsidized by the government. In certain cases, the benefits may even be better than the Gold or Platinum plans.