November 2014 – CA Health Insurance Newsletter

November 2014 – CA Health Insurance Newsletter

Welcome to our quarterly newsletter with information on healthcare insurance, long term care, and other strategies to protect your family’s financial future. This edition will focus on healthcare for those under age 65 as well as those over age 65 because we are just starting the open enrollment period for both age categories (November 15th through February 15th for under age 65 and October 15th through December 7th for over age 65). Most of you already have health insurance through your job, but you may have children or family that don’t have coverage or are paying too much for an old health plan.  In some cases you or a family member may be able to obtain a quality health plan for little cost.

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“Obamacare” or the “Affordable Healthcare Act (ACA) has created a new healthcare landscape with mostly new simplified improved options. You may currently have a plan that is not required to follow some of the new laws such as offering preventative health services without co-payment from you or raising your rates based on your health status.


Two good features of the new law are that all who apply for health coverage are guaranteed acceptance and all plans have a maximum out of pocket cost to the insured ($6,350 for an individual) so that a catastrophe does not bankrupt a family. All plans must offer at least 10 essential health benefits and cover certain types of preventative care at no cost including an annual checkup.  For those with lower income or near the poverty level, premium costs are subsidized so that healthcare is “affordable” meaning less than 9.5% of their gross income. Plans are divided into 4 tiers called bronze, silver, gold, and platinum so that tiers of all insurance company’s plans have identical co-pays and deductible costs.  The insured’s share of the cost ranges from 10% with platinum to 40% with bronze. Unlike the past with many variables that each plan offered, It’s much easier to compare service levels of company health plans. The only decision points with the new plans are premium cost and whether you like the provider network of each insurance company.


On the flip side the new law requires that everyone must get health insurance or pay a penalty. As a result, the healthy, wealthy and young will subsidize the unhealthy, older and poor. Fortunately, the claims paid experience of the health insurance industry was good enough in the first 7 months of the ACA program to allow only an average cost increase of 5.9% nationwide. Another negative for those receiving a subsidy is that the provider networks available to treat the insured has been narrowed down such that some people might not find a plan that  their doctor accepts and must find a new doctor. Finally, the law was somewhat modeled after “Medicare”  over age 65 coverage and therefore the lower cost plans have considerable co-pay costs for brand drugs, urgent care center use, etc. I believe this is a positive because healthy people save money on premiums but have the ability to upgrade their coverage every year.


We won’t delve into all the healthcare law but here is a link to an article I wrote and posted on our website which covers common questions about the new law and especially about the subsidized plans. CLICK HERE

However, it is worth explaining the different types of under age 65 health plans because there is confusion over this topic. There are 3 categories of health plans for individuals.  The 4 tier metal plans are based on the level of coverage you want. The exchange subsidized plans are based on your adjusted gross income from your tax return. (1) Those below poverty (about $18,000 for an individual in California) qualify for the Federal Medicaid program which has been around since 1965. This program is called “medi-cal” in California because it is run by the state. The doctor network for Medicaid/Medi-cal is limited due to low reimbursement paid to providers. (2)  For those with income above poverty- up to 400% above poverty a subsidy is available either from your state health exchange such as Covered California or from the Federal government exchange. There are usually 4 or 5 insurance carriers in each market area that offer “exchange” plans. Because a person’s health cost should not exceed 9.5% of their gross income, the premium cost subsidy is much greater for older insured compared to the younger. (3)  For those who make over 400% of poverty, no subsidy is available so that person or family has to go to the “off exchange” market.  The good news is the off exchange plans include all of the plans that are on the exchange but with no subsidy, plus additional plans that may have greater provider networks such as PPO plans. We told you it was confusing!


Like Medicaid for the poor, the Medicare program to provide senior citizens with health insurance has been around since 1965. In my opinion anyone who is eligible should get on this  coverage as soon as possible unless they have work health insurance 100% paid for by their employer.  The premium costs are cheaper than under age 65 health coverage ($104 to $400 per month) and the coverage is robust because the program has been in place for decades. There are instances where it makes sense to get off work insurance or a plan you have for your family and get on medicare because the cost may be lower. An example would be where an employee pays for his dependent coverage through work but his coverage is paid by work. It may cost less to get his family their own ACA plan while he gets Medicare coverage.

Medicare has 3 types of plans. (1) “Original Medicare”, or part A and B is where your hospital or doctor bills the government for any services provided to you and you must pay a co-pay and deductibles.   (2) “Medicare Advantage” or Part C is a plan where your care is managed by a private insurance company on behalf of the government. These plans are usually HMO type and they comprehensively manage your healthcare often at the same cost to the insured as original Medicare. Part C plans usually offer the insured many extra benefits such as a drug plan, gym membership, and sometimes lower co-pays. Both original medicare and the part C Advantage plans must accept all applicants. (3) Medi-gap or Medicare Supplemental plans are the best plans because they offer to cover most of the co-pays and deductibles required with original Medicare.  Like original Medicare they allow you to see any doctor that takes Medicare anywhere in the United States. The med sup or medi-gap plans do cost extra on top of the cost of basic Medicare part A and B.  Med Sup plans and original Medicare involve separate drug plans at an additional cost. These drug plans have higher co-pays for brand and special drugs so the plans should be reviewed each year if the insured uses costly drugs in order to make sure their plan is the best cost for the following year. Each year Medicare members are allowed to review their plans and change them if they find better or cheaper plans in the market.

Open enrollment for under age 65 and annual enrollment for Medicare members are about to happen. There are many details we didn’t go into in that you may have questions about, we will be happy to answer any of your questions.