Health Plan Market
&
Benefit Comparison Part II
Presented by Cliff Craig
Health Plan Account Manager for Connect for Health Colorado
Key Topics to be Discussed
•
Family Deductible & Out-of-Pocket maximum Accumulation
•
High Deductible Health Plan (HDHP) / Health Savings Account (HSA)
•
Key Features of the SBC & Plan Document Page
•
Market Place Carrier Review & Product Offering
o
o
o
o
2
Health Shop / Small Group
Health Individual
Dental Shop / Small Group
Dental Individual
•
Carriers Benefit Comparison by Metal Tiers
•
Carrier Specific Key Points & Service Area
2
Market Place Plan Types
Health Maintenance Organization (HMO)
A type of health insurance plan that usually limits coverage to care from doctors who
work for or contract with the HMO. It generally won’t cover out-of-network care except
in an emergency. An HMO may require you to live or work in its service area to be
eligible for coverage. HMOs often provide integrated care and focus on prevention and
wellness. (No Out of Network Coverage)
Preferred Provider Organization (PPO)
A type of health plan that contracts with medical providers, such as hospitals and
doctors, to create a network of participating providers. You pay less if you use providers
that belong to the plan’s network. You can use doctors, hospitals and providers outside
of the network for an additional cost.
(Out of Network Coverage but at Higher Cost-sharing)
Exclusive Provider Organization (EPO)
A more restrictive type of preferred provider organization plan under which employees
must use providers from the specified network of physicians and hospitals to receive
coverage; there is no coverage for care received from a non-network provider except in
an emergency situation. (No Out of Network Coverage)
3
3
Family Deductible and
Out-of-Pocket Maximum
Accumulation
This is a representative sample of the Carrier's plans and rates.
It is not intended to promote one Carrier over another Carrier
4
What Applies to Maximum Out-of-Pocket
HMO & EPO Plans
Copayments
Deductibles
Rx
Deductibles
Coinsurance
Rx
Coinsurance
Rx
Copayments
Maximum
Out-of-Pocket
$6,350 / $12,700
Prevention
5
5
Embedded VS Aggregate Family
Deductibles & Out-of-Pocket Maximums
There are two different types of deductibles: traditional, also called Embedded(PerMember), and Aggregate (Single), also known as non-embedded.
Embedded Family Deductible & Out-of-Pocket maximum (Most Common)
If you are on a family (two or more members covered) medical plan with an
Embedded deductible, your plan contains two components, an individual deductible
and a family deductible. Having two components to the deductible allows each
member of your family the opportunity to get her medical bills covered prior to the
entire dollar amount of the family deductible being met. The individual deductible is
embedded in the family deductible.
Aggregate Family Deductible & Out-of-Pocket maximum (Primarily Used with HSA’s)
If your insurance policy contains a Aggregate family deductible, an individual
deductible is not embedded in the family deductible. In this situation, before your
insurance helps you pay for any of your family's medical bills, the entire amount of the
deductible must be met. It can be met by one family member or by a combination of
family members. There are no benefits until expenses equaling the deductible amount
have been incurred.
6
6
Embedded / Per-Member Family Deductible
& Out-of-Pocket Maximum
Prevention
Father
$2000
Mother
$3000
Child
$500
$3000 Individual
$6000 Family Deductible
Each family member
must meet the
Individual Deductible
before coinsurance
applies for them only
Coinsurance
Father
7
Mother
$6350
Child
$6350 Individual
$12700 Family OOP Max.
7
Embedded / Per-Member Family Deductible
& Out-of-Pocket Maximum
Prevention
Father
$3000
Mother
$3000
Child
$3000 Individual
$6000 Family Deductible
Coinsurance
Father
$6350
8
Mother
$6350
Each family member
must meet the
Individual Deductible
before coinsurance
applies for them only or
combined by two or
more then the family
moves to coinsurance
Child
$6350 Individual
$12700 Family OOP Max.
8
Embedded / Per-Member Family Deductible
& Out-of-Pocket Maximum
Prevention
Father
$2000
The mother was the
only family member
accessing care. She
met her Individual Deductible
& Out-of-Pocket max so she is
the only family member covered
at 100%
Child
$500
$3000 Individual
$6000 Family Deductible
Coinsurance
Father
9
Mother
$3000
Mother
$6350
Child
$6350 Individual
$12700 Family OOP Max.
9
Aggregate / Single Family Deductible
& Out-of-Pocket Maximum
Prevention
Father
$2000
Mother
$3500
Child
$500
$3000 Individual
$6000 Family Deductible
The family as a group
can meet the Family
Deductible
Coinsurance for all
Family members
10
10
Aggregate / Single Family Deductible
& Out-of-Pocket Maximum
Prevention
$3000 Individual
$6000 Family Deductible
Coinsurance for all
Family members
Father
$6000
Mother
$5000
The family as a group
has met the Family
Out-Of-Pocket Max.
Child
$1700
$6350 Individual
$12700 Family OOP Max.
11
11
Aggregate / Single Family Deductible
& Out-of-Pocket Maximum
Prevention
Father
$2000
Mother
$3500
Child
$500
$3000 Individual
$6000 Family Deductible
The family as a group
met the Family
Deductible & the Family
Out-of-Pocket Max.
Coinsurance
Father
$6000
12
Mother
$5000
Child
$1700
$6350 Individual
$12700 Family OOP Max.
12
Aggregate / Single Family Deductible
& Out-of-Pocket Maximum
Prevention
Father
Mother
$6000
Child
$3000 Individual
$6000 Family Deductible
The mother was the
only family member
accessing care. She
met the Family Deductible
& Out-of-Pocket max for the
entire family
Coinsurance
Father
13
Mother
$12700
Child
$6350 Individual
$12700 Family OOP Max.
13
Sample of How Benefits Accumulate for a
Family of Three Policy
RMHP West Focus HMO Silver $2500/Copay $40
•
Medical Deductible = $2,500 / $5,000
Drug Deductible = $500 / $1000
Out-of-Pocket Max. = $6,350 / $12,700
•
PCP visit = $40 Copay / Specialist = $55 Copay
•
Prescription Drugs = $15 Generic / 30% (After
Ded.) Preferred Brand / 40% (After Ded.) NonPreferred & Specialty
•
Facilities = 30% Coinsurance (After Ded.)
Outpatient / Inpatient Surgery
•
Emergency Care = 30% Copay Urgent care /
$250 Copay Emergency Room / 30% coin.
(After Ded.) Ambul.
•
Testing = 30% coinsurance (After Ded.)
CT/PET Scans, MRIs / X-rays / Lab.
Family
Dads Medical Services
Cost of services
expenses
Prevention visit
$100
$0
PCP visit
$100
$40
PCP orders meds Preferred
$140
$140
Inpatient Hospital (2nd)
$5,000
$3,600
(Dad paid $3000 & $600 (30% of $2000)
X-rays & Lab
$1,000
$300
Physician surgery
$1,000
$300
InptHospmeds 1 Pref / 1 Spec
Emergency visit (4th)
Dads Total
Moms Medical Services
Prevention visit
OB/GYN Visit
PCP visit
OutPatient Surgery (3rd)
Lab
Outpt meds Preferred
Outpt meds Preferred
Outpt meds Generic
Moms Total
Baby Bears Medical Services
Prevention visit
Emergency visit (1st)
Ambulance ride to ER
ER test MRI
ER meds Specialty Drug
ER med Preferred
ER med Generic
Baby Bears Total
Family Total
14
Applies to Applies to Rx
Med Ded
Ded
$0
$0
$0
$0
$0
$140
$3,000
Family Ded met
done
$0
done
$0
Applies to
OOP max
$0
$40
$140
$3,600
RMHP
expenses
$100
$60
$0
$1,400
$300
$300
$700
$700
$400
$2,000
$9,740
$400
$600
$5,380
$0
done
$3,000
$400
$0
$540
$400
$600
$5,380
$0
$1,400
$4,360
$150
$200
$100
$2,000
$500
$110
$200
$75
$3,335
$0
$40
$40
$600
$150
$110
$60
$15
$1,015
$0
$0
$0
done
done
$0
$0
$0
$0
$0
$0
$0
$0
$0
$110
done
done
$110
$0
$40
$40
$600
$150
$110
$60
$15
$1,015
$150
$160
$60
$1,400
$350
$0
$140
$60
$2,320
$80
$1,000
$1,000
$1,000
$200
$150
$75
$3,505
$16,580
$0
$250
$1,000
$1,000
$200
$150
$15
$2,615
$9,010
$0
$0
$1,000
$1,000
$0
$0
$0
$2,000
$5,000
$0
$0
$0
$0
$200
$150
$0
$350
$1,000
$0
$250
$1,000
$1,000
$200
$150
$15
$2,615
$9,010
$80
$750
$0
$0
$0
$0
$60
$890
$7,570
14
High Deductible Health Plan (HDHP)
&
Health Savings Account (HSA)
This is a representative sample of the Carrier's plans and rates.
It is not intended to promote one Carrier over another Carrier
15
Health Savings Account (HSA)
Health Savings Account (HSA)
A medical savings account available to taxpayers who are enrolled in a qualified High
Deductible Health Plan (HDHP). The funds contributed to the account aren’t subject to
federal income tax at the time of deposit. Funds must be used to pay for qualified
medical expenses. Unlike a Flexible Spending Account (FSA), funds roll over year to year
if you don’t spend them.
• HDHP / HSA can be associated with any plan types – HMO, PPO, & EPO
• To open an HSA account the plan type MUST be a QUALIFIED HDHP product
• The amount a person can contribute to their HSA account on an annual basis is
based on the plan types Deductible level.
• Employers can also contribute to their employees HSA account, but the employer
and the employees contribution cannot exceed the Deductible level.
• A person can use funds from their HSA account to pay for covered & non-covered
medical services, a Federal regulation list will show qualified medical expenses.
• There is a tax penalty for withdrawing funds from your HSA account to pay for nonmedical expenses, before the age 65.
16
16
HSA Contribution Limits for 2014
Contribution and Out-of-Pocket Limits for Health Savings Accounts and for High-Deductible Health Plans
For 2014
For 2013
Changes
Individual:
$3,300
Family:
$6,550
Individual:
$3,250
Individual:
+$50
Family:
$6,450
Family:
+100
HSA catch-up contributions
(age 55 or older)*
$1,000
$1,000
No change**
HDHP minimum deductibles
Individual:
$1,250
Family:
$2,500
Individual:
$1,250
No change
Individual:
$6,350
Family:
$12,700
Individual:
$6,250
Individual:
+$100
Family:
$12,500
Family:
+$200
HSA contribution limit
(employer + employee)
HDHP maximum out-of-pocket
amounts (deductibles, copayments and other amounts,
but not premiums)
Family:
$2,500
* Catch-up contributions can be made any time during the year in which the HSA participant turns 55.
** Unlike other limits, the HSA catch-up contribution amount is not indexed; any increase would require statutory change.
17
17
HSA Penalties & Children Coverage
18
Penalties for Nonqualified Expenses
Those under age 65 (unless totally and permanently disabled) who use HSA funds for
nonqualified medical expenses face a penalty of 20 percent of the funds used for such expenses.
Funds spent for nonqualified purposes are also subject to income tax.
Coverage of Adult Children
While the Patient Protection and Affordable Care Act allows parents to add their adult children
(up to age 26) to their health plans, the IRS has not changed its definition of a dependent for
health savings accounts. This means that an employee whose 24-year-old child is covered on his
HSA-qualified high-deductible health plan is not eligible to use HSA funds to pay that child’s
medical bills.
If account holders can't claim a child as a dependent on their tax returns, then they can't spend
HSA dollars on services provided to that child. According to the IRS definition, a dependent is a
qualifying child (daughter, son, stepchild, sibling or stepsibling, or any descendant of these) who:
• Has the same principal place of abode as the covered employee for more than one-half of
the taxable year.
• Has not provided more than one-half of his or her own support during the taxable year.
• Is not yet 19 (or, if a student, not yet 24) at the end of the tax year or is permanently and
totally disabled.
18
Health Savings Account (HSA) /
High Deductible Health Plans (HDHP) Eligible Plans
11
9 9
9
3
2
0 0
2
0
2 2
0
2
0
Individual
19
0 0
2
0
0
2
0
Small Group
19
What Applies to Maximum Out-of-Pocket
HSA & HDHP Plans
Prevention
Copayments
Deductibles
Coinsurance
Rx
Copayments
Maximum
Out-of-Pocket
$6,350 / $12,700
20
20
Benefit Comparison for HSA Products
Kaiser Permanente Sample
Kaiser Permanente H.S.A Plans
Benefits
Bronze 5000/30% H.S.A
Bronze 4500/50 H.S.A
Silver 1750/25% H.S.A.
Ded Individual
$5,000
$4,500
$1,750
Ded Family
$10,000
$9,000
$3,500
OOPMax Ind
$6,530
$6,350
$5,000
OOPMax Family
$12,700
$12,700
$10,000
Primary Care
30% Coin / After Ded
$50 Copay / After Ded
25% Coin / After Ded
Specialist visit
30% Coin / After Ded
$70 Copay / After Ded
25% Coin / After Ded
Prevention visit
No Charge $0 Copay
No Charge $0 Copay
No Charge $0 Copay
Diagnostic Test
30% Coin / After Ded
30% Coin / After Ded
25% Coin / After Ded
Imaging
30% Coin / After Ded
$500 Copay / After Ded
25% Coin / After Ded
Generic Drugs
$20 copay / After Ded
$20 Copay / After Ded
$15 Copay / After Ded
Preferred Drugs
30% Coin / After Ded
$50 Copay / After Ded
$45 Copay / After Ded
Non-Preferred
30% Coin / After Ded
30% Coin / After Ded
25% Coin / After Ded
Specialty Drugs
30% Coin / After Ded
30% Coin / After Ded
25% Coin / After Ded
Facility Outpatient
30% Coin / After Ded
30% Coin / After Ded
25% Coin / After Ded
Facility Inpatient
30% Coin / After Ded
$500 Copay / After Ded
25% Coin / After Ded
Emergency visit
30% Coin / After Ded
$500 Copay / After Ded
25% Coin / After Ded
Emergency Trans
30% Coin / After Ded
30% Coin / After Ded
25% Coin / After Ded
Urgent Care
30% Coin / After Ded
30% Coin / After Ded
25% Coin / After Ded
$158.37
$164.97
$208.52
4%
24%
Premium
% increase Lowest Plan
21
21
Benefit Comparison for HSA Products
Rocky Mountain Health Plan Sample
Rocky Mountain Health Plans H.S.A Plans
Benefits
Bronze $6300/100% H.S.A
Bronze PPO 6300/100% H.S.A
Silver PPO 2500/100% H.S.A
Ded Individual
$6,300
$6,300
$12,600
$2,500
$5,000
Ded Family
$12,600
$12,600
$25,200
$5,000
$10,000
OOPMax Ind
$6,300
$6,300
$12,600
$6,350
$12,700
OOPMax Family
$12,600
$12,600
$25,200
$12,700
$25,400
Primary Care
No Charge After Ded
No Charge After Ded
No Charge After Ded
No Charge After Ded
No Charge After Ded
Specialist visit
No Charge After Ded
No Charge After Ded
No Charge After Ded
No Charge After Ded
No Charge After Ded
Prevention visit
No Charge $0 Copay
No Charge $0 Copay
Varies
No Charge $0 Copay
Varies
Diagnostic Test
No Charge After Ded
No Charge After Ded
No Charge After Ded
No Charge After Ded
No Charge After Ded
Imaging
No Charge After Ded
No Charge After Ded
No Charge After Ded
No Charge After Ded
No Charge After Ded
Generic Drugs
No Charge After Ded
No Charge After Ded
Not Covered
No Charge After Ded
Not Covered
Preferred Drugs
No Charge After Ded
No Charge After Ded
Not Covered
No Charge After Ded
Not Covered
Non-Preferred
No Charge After Ded
No Charge After Ded
Not Covered
No Charge After Ded
Not Covered
Specialty Drugs
No Charge After Ded
No Charge After Ded
Not Covered
No Charge After Ded
Not Covered
Facility Outpatient
No Charge After Ded
No Charge After Ded
No Charge After Ded
No Charge After Ded
No Charge After Ded
Facility Inpatient
No Charge After Ded
No Charge After Ded
No Charge After Ded
No Charge After Ded
No Charge After Ded
Emergency visit
No Charge After Ded
No Charge After Ded
No Charge After Ded
No Charge After Ded
No Charge After Ded
Emergency Trans
No Charge After Ded
No Charge After Ded
No Charge After Ded
No Charge After Ded
No Charge After Ded
Urgent Care
No Charge After Ded
No Charge After Ded
No Charge After Ded
No Charge After Ded
No Charge After Ded
Premium
$226.90
% increase Lowest Plan
22
$258.06
$323.61
12%
30%
22
Key Features of the SBC
& Plan Document Page
This is a representative sample of the Carrier's plans and rates.
It is not intended to promote one Carrier over another Carrier
23
Plan Documents Can Help Make Final Decision
Evidence of Coverage, Policy,
Summary of Benefits: It’s the members
Contract with the carrier
(about 80 plus pages) varies by carrier
English only
Company Profile: Standard document
Covers – Company at a glance, Medical
Loss Ratio, Unique Offerings & Programs,
Awards & Recognition,& In the Community.
English & Spanish
Carrier Marketing materials:
Not Standard, Varies by carrier
English & Spanish
24
Summary of Benefits and Coverage, is a summary
of benefits (not a binding contract), standard benefit
Layout (9 pages) English & Spanish
Quality Overview: Standard Document Covers –
Accreditations, Consumer Complaints, How the plan
makes members healthier / works with providers /
examples of innovative approaches, Quality Ratings.
English & Spanish
24
Key Things to Know When Using
Plan Compare Function
Issue with the Plan Compare is neither product has an In Network Tier Two benefit listed and
the PPO plan is not illustrating the Out of Network Tier benefit information
25
25
Key Things to Know When Using
Plan Compare Function
The compare function is utilized
best when comparing two different
carriers or plans that are close in
premium and now its which one
provides the best benefit for the
COST
26
26
Key Things to Know When Using
Plan Compare Excel File
This is a snapshot of 2 Colorado HealthOP Bighorn EPO ($276.42) & PPO ($315.78)
In Network (Tier 1)
In Network (Tier 2)
In Network (Tier 1)
In Network (Tier 2)
Primary Care Visit to Treat an Injury or
Illness
Copay
Coinsurance
$30
No Charge
$30
No Charge
Other Practitioner Office Visit (Nurse,
Physician Assistant)
Copay
Coinsurance
$60
No Charge
$60
No Charge
Preventive Care/Screening/Immunization
Copay
Coinsurance
$0
No Charge
$0
No Charge
Specialist Visit
Copay
Coinsurance
$60
$60
No Charge
No Charge
Copay
No Charge
No Charge
Coinsurance
35% Coinsurance after deductible
35% Coinsurance after deductible
Nutritional Counseling
Issue with the Plan Compare is neither product has an In Network Tier Two benefit listed and
the PPO plan is not illustrating the Out of Network Tier benefit information
27
27
Colorado HealthOP Bison PPO
Plan Benefits Page Information
Notice the Enhance benefit
information is not listed on the
Plan Benefits Page.
The In-Network Tier 2 benefit is
unique to CO HealthOP only
28
28
Colorado HealthOP Bison EPO Plan
SBC Information
Services You May Need
Primary care visit to treat an injury
or illness
Specialist visit
Your Cost If You Use a
Network Provider
Your Cost If You
Use a
Non-Network
Provider
Standard
First visit free subject to the
deductible. Subsequent visits are
40% coinsurance/visit.
Not Covered
Enhanced*
First visit free. Subsequent visits
$30 copayment/visit and not
subject to the deductible.
Standard
40% coinsurance/visit
* The first primary care visit is
free in enhanced plans only if
the member has not already
received a free visit in the
standard plan.
Not Covered
---None---
Not Covered
---None---
Enhanced*
$60 copayment/visit
Standard
40% coinsurance/visit
Other practitioner office visit
Limitations & Exceptions
Enhanced*
40% coinsurance/visit
Once You and Your enrolled Spouse (if applicable), complete the personal health actions identified under You personal account on Our
website, www.COHealthOp.org or upon request Our Customer Service, You will be rewarded with financial incentives. The incentive
types and amounts vary by the Plan(s) elected. See the Enhanced Network Coinsurance/Copayments
column on the Schedule of Benefits in this Certificate for details regarding Your plan incentives. Note: Charges for medical care
required under the personal health actions will be covered under the Preventive and Wellness Services and Chronic Disease
Management provision of the Benefits/Coverages (What is Covered) section of this Certificate
29
29
Plan Page Benefit Clarification HMO & EPO
All HMO & EPO products only
offer In Network (Tier 1) benefits,
the Out of Network benefits
$0 & 100% should be clarified
as Not Covered. PPO plans will
have benefit levels listed in both
In Network & Out of Network tiers
30
30
Sample of an HMO SBC Regarding
Emergency Room Benefits
Common
Medical Event
Services You May Need
Level 1 – Preferred Generic
If you need drugs to
treat your illness or
condition
Level 2 – Non-preferred Generic
Level 3 – Preferred Brand
Your Cost If
You Use an
Network
Provider
$10 copay (Retail)
$20 copay
(Mail Order)
Your Cost If
You Use an
Non-network
Provider
Not Covered
$20 copay (Retail)
$40 copay
(Mail Order)
$50 copay (Retail)
$100 copay
(Mail Order)
50% coinsurance
Not Covered
Not Covered
Limitations & Exceptions
Preauthorization required, penalty may
apply.
30 day supply (Retail)
90 day supply (Mail Order)
See Level 1 for Limitations and
Exceptions
See Level 1 for Limitations and
Exceptions
information
AllMore
Emergency
Services are treated as In Network benefits regardless of Facility.
about prescription
See Level 1benefits
for Limitations and
Level
4 – Non-preferred
Brand because it shows Out
Not Covered
The
is miss
leading
of Network
as $0 & 100%
drugPlan
coveragePage
is
Exceptions
available at
www.humana.com.
Urgent care is listed
In Network
only and
at a Copay
level for
some plans
Preauthorization
required, penalty may
Level 5 – Specialty
drugs
50% coinsurance
Not Covered
If you have
outpatient surgery
If you need
immediate medical
attention
If you have a
hospital stay
31
apply.
40% coinsurance when filled via a
preferred network specialty pharmacy
Preauthorization required, penalty may
apply.
-----------------none-----------------------------------------none-------------------------
Facility fee (e.g., ambulatory surgery center)
20% coinsurance
Not Covered
Physician/surgeon fees
Emergency room services
Emergency medical transportation
20% coinsurance
20% coinsurance
20% coinsurance
Not Covered
20% coinsurance
20% coinsurance
Urgent care
$50 copay/visit
Not Covered
Cost share may vary based on where
service is performed.
Facility fee (e.g., hospital room)
20% coinsurance
Not Covered
Physician/surgeon fee
20% coinsurance
Not Covered
Preauthorization required, penalty may
apply.
-----------------none-------------------------
-----------------none-------------------------
31
Sample of an HMO SBC Regarding
Unique Five Tier Rx Benefits
Common
Medical Event
Services You May Need
Level 1 – Preferred Generic
If you need drugs to
treat your illness or
condition
More information
about prescription
drug coverage is
available at
www.humana.com.
Level 2 – Non-preferred Generic
Level 3 – Preferred Brand
Level 4 – Non-preferred Brand
Your Cost If
You Use an
Network
Provider
$10 copay (Retail)
$20 copay
(Mail Order)
Your Cost If
You Use an
Non-network
Provider
Not Covered
$20 copay (Retail)
$40 copay
(Mail Order)
$50 copay (Retail)
$100 copay
(Mail Order)
50% coinsurance
Not Covered
Limitations & Exceptions
Preauthorization required, penalty may
apply.
30 day supply (Retail)
90 day supply (Mail Order)
See Level 1 for Limitations and
Exceptions
Not Covered
See Level 1 for Limitations and
Exceptions
Not Covered
See Level 1 for Limitations and
Exceptions
Preauthorization required, penalty may
apply.
40% coinsurance when filled via a
preferred network specialty pharmacy
Preauthorization required, penalty may
Facility fee (e.g., ambulatory surgery center)
20% coinsurance
Not Covered
you have
ThisIfplan
has a five tier Rx benefit: Tier 1 Preferred Generic, Tier 2 Non-Preferred
Generic
apply.
outpatient surgery
Physician/surgeon
20% coinsurance
Covered
-----------------none------------------------Tier 3 Preferred Brand,
Tier 4 fees
Non-Preferred Brand,
Tier 5 Not
Specialty
Drugs.
Emergency room services
20% coinsurance
20% coinsurance
-----------------none------------------------The Tier 2 Non-preferred
Generic is very unique
Emergency medical transportation
20% coinsurance
20% coinsurance
If you need
-----------------none------------------------immediate medical
Cost share may vary based on where
Urgent care
copay/visit
Not Covered
attention
Carriers
only use one
Pharmacy Network, for $50
PPO
plans when
Out of Network
providers write
service is performed.
Level 5 – Specialty drugs
50% coinsurance
Not Covered
Facility fee (e.g., hospital room)
20% coinsurance
Not Covered
Physician/surgeon fee
20% coinsurance
Not Covered
a script there is no difference in cost sharing
If you have a
hospital stay
32
Preauthorization required, penalty may
apply.
-----------------none------------------------32
Sample of an HMO SBC Regarding
Outpatient & Inpatient Benefits
Common
Medical Event
Your Cost If
You Use an
Network
Provider
$10 copay (Retail)
$20 copay
(Mail Order)
Your Cost If
You Use an
Non-network
Provider
Not Covered
$20 copay (Retail)
$40 copay
(Mail Order)
$50 copay (Retail)
$100 copay
(Mail Order)
50% coinsurance
Not Covered
Level 5 – Specialty drugs
50% coinsurance
Not Covered
Facility fee (e.g., ambulatory surgery center)
20% coinsurance
Not Covered
Physician/surgeon fees
Emergency room services
Emergency medical transportation
20% coinsurance
20% coinsurance
20% coinsurance
Not Covered
20% coinsurance
20% coinsurance
Urgent care
$50 copay/visit
Not Covered
Cost share may vary based on where
service is performed.
Facility fee (e.g., hospital room)
20% coinsurance
Not Covered
Physician/surgeon fee
20% coinsurance
Not Covered
Preauthorization required, penalty may
apply.
-----------------none-------------------------
Services You May Need
Level 1 – Preferred Generic
If you need drugs to
treat your illness or
condition
Level 2 – Non-preferred Generic
Limitations & Exceptions
Preauthorization required, penalty may
apply.
30 day supply (Retail)
90 day supply (Mail Order)
See Level 1 for Limitations and
Exceptions
Outpatient Surgery
Hospital
Stay separate Facility
fees andSeePhysician
fees
Level 3 &
– Preferred
Brand
Not Covered
Level 1 for Limitations
and
Exceptions
More information
benefits
for this example both are at a coinsurance level. Some plans will provide
about prescription
See Level 1 for Limitations and
Level 4 – Non-preferred
Brand benefit
Not Covered
drug coverage
is
a copay
at the
Facility
fee level
Exceptions
available at
www.humana.com.
If you have
outpatient surgery
If you need
immediate medical
attention
If you have a
hospital stay
33
Preauthorization required, penalty may
apply.
40% coinsurance when filled via a
preferred network specialty pharmacy
Preauthorization required, penalty may
apply.
-----------------none-----------------------------------------none-----------------------------------------none-------------------------
33
Sample of An UnitedHealthcare SBC
Single Individual Family Deductible
Notice UHC does not provide a Family Deductible level. Each family member
must meet a $5000 per person Deductible before coinsurance applies
Important Questions Answers
Why this Matters:
What is the overall
deductible?
$5,000 per person per calendar year.
Deductible does not apply to preventive
care or outpatient prescription drugs.
Coinsurance and copayments don’t
count toward the deductible.
You must pay all the costs up to the deductible amount before this plan begins to pay for
covered services you use. Check your policy or plan document to see when the deductible
starts over (usually, but not always, January 1st). See the chart starting on page 2 for how
much you pay for covered services after you meet the deductible.
Are there other
deductibles for specific
services?
Yes. $500 per person per calendar year
for Tiers 2-4 outpatient prescription
drugs. There are no other specific
deductibles.
You must pay all the costs for these services up to the specific deductible amount before
this plan begins to pay for these services.
Is there an out–of–
pocket limit on my
expenses?
Yes. $6,350 per person and $12,700 per
The out-of-pocket limit is the most you could pay during a coverage period (usually one
family per calendar year. Other limits
year) for your share of the cost of covered services. This limit helps you plan for health care
apply – see the chart that starts on page 2. expenses.
34
34
Sample Colorado HealthOP SBC Mental
Health Benefits
Common
Medical Event
Services You May Need
Your Cost If You Use a
Network Provider
Your Cost If You
Use a
Non-Network
Provider
Limitations & Exceptions
Early Intervention Services are
limited to 45 visits per year.
Mental/Behavioral health
outpatient services
If you have mental
health, behavioral
health, or substance
abuse needs
Enhanced*
$40 copayment/visit
Not Covered
Autism-Applied Behavioral
Analysis is limited to 550
sessions from birth to age 8 and
185 sessions age 9-19 (sessions
being 25 minute increments)
Preauthorization required
Mental/Behavioral health inpatient
services
Substance use disorder outpatient
services
Substance use disorder inpatient
services
35
Standard
$60 copayment/visit
Standard
35% coinsurance/admission
Enhanced*
35% coinsurance/admission
Standard
$60 copayment/visit
Enhanced*
$40 copayment/visit
Standard
35% coinsurance/admission
Enhanced*
35% coinsurance/admission
Not Covered
Preauthorization required.
Not Covered
Preauthorization required.
Not Covered
Preauthorization required.
35
Sample Kaiser Permanente’s SBC
Rehabilitation Benefits
Common
Medical Event
Services You May
Need
Home health care
Your Cost If You Use a Plan
Provider
40% coinsurance
40% coinsurance for outpatient services;
Rehabilitation services See Facility fee under "If you have a
hospital stay" for inpatient services.
If you need help
recovering or have
other special health
needs
36
Habilitation services
40% coinsurance for outpatient services
Skilled nursing care
40% coinsurance
Durable medical
equipment
40% coinsurance
Hospice service
40% coinsurance
Your Cost
If You Use Limitations & Exceptions
a Non-Plan
Provider
Limited to less than 8 hours per day and 28
Not covered
hours per week
Combined outpatient visit limit between
rehabilitation and habilitation services of 40
visits per therapy per year (autism spectrum
Not covered
disorders are not subject to the visit limit);
Inpatient in a multi-disciplinary facility limited
to 60 days per condition per year.
Combined outpatient visit limit between
rehabilitation and habilitation services of 40
Not covered
visits per therapy per year (autism spectrum
disorders are not subject to the visit limit).
Not covered Limited to 100 days per year
Coverage is limited to items on our DME
Not covered formulary. Prosthetic arms and legs at 20%
coinsurance (not subject to the deductible).
Not covered
---none---
36
Sample of The SBC’s Excluded & Other
Covered Services Section
This section could vary by carrier & plan type, notice the disclaimer
“ Check your policy or plan document”
Excluded Services & Other Covered Services:
Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.)

Acupuncture

Child glasses

Long- term care

Bariatric surgery

Child dental check up


Cosmetic surgery, unless to correct a
functional impairment caused by injury,
infection, disease

Dental care (Adult)
Non-emergency care when traveling outside
the U.S. except as required by law for
emergency care

Infertility treatment

Weight loss program
Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these
services.)
37

Chiropractic care – spinal manipulations are
covered

Child eye exam

Hearing aids (under age 18)


Routine eye care (Adult) when in treatment
for diabetes
Routine foot care when in treatment for
diabetes

Private-duty nursing – medically necessary
Inpatient only
37
Each SBC Provides A Coverage Sample
About these Coverage
Examples:
These examples show how this plan might cover
medical care in given situations. Use these
examples to see, in general, how much financial
protection a sample patient might get if they are
covered under different plans.
This is
not a cost
estimator.
Don’t use these examples to
estimate your actual costs
under this plan. The actual
care you receive will be
different from these
examples, and the cost of
that care will also be
different.
See the next page for
important information about
these examples.
38
Having a baby
Managing type 2 diabetes
(normal delivery)
(routine maintenance of
a well-controlled condition)
 Amount owed to providers: $7,540
 Plan pays $5,020
 Patient pays $2,520
Sample care costs:
Hospital charges (mother)
Routine obstetric care
Hospital charges (baby)
Anesthesia
Laboratory tests
Prescriptions
Radiology
Vaccines, other preventive
Total
$2,700
$2,100
$900
$900
$500
$200
$200
$40
$7,540
Patient pays:
Deductibles
Co-pays
Co-insurance
Limits or exclusions
Total
$1,000
$20
$1,300
$200
$2,520
 Amount owed to providers: $5,400
 Plan pays $4,320
 Patient pays $1,080
Sample care costs:
Prescriptions
Medical Equipment and Supplies
Office Visits and Procedures
Education
Laboratory tests
Vaccines, other preventive
Total
$2,900
$1,300
$700
$300
$100
$100
$5,400
Patient pays:
Deductibles
Co-pays
Co-insurance
Limits or exclusions
Total
$100
$600
$300
$80
$1,080
38
Market Place Carrier Review
& Product Offering
This is a representative sample of the Carrier's plans and rates.
It is not intended to promote one Carrier over another Carrier
39
C4HCO Carrier Partners' by Market
Carrier Consumer Facing Name / DBA
T
Individual Health Plans Group Health Plans Dental Individual Plans Dental Group Plans
Access Health Colorado
H
Colorado Choice Health Plans
H
Colorado HealthOP
H
Denver Health Medical Plan
H
Humana
H
Kaiser Permanente
H
Rocky Mountain Health Plans
H
SeeChange Health
H
UnitedHealthcare / All Savers
H
X
Anthem Blue Cross & Blue Shield / HMO
Colorado
B
Cigna
B
X
X
Best Life & Health Insurance Company
D
Dentegra Insurance Company
D
Guardian
D
Premier Access Dental & Vision
D
40
X
X
X
X
X
X
D
Delta Dental of Colorado
MetLife
X
X
X
X
X
X
X
D
Total by Participation
X
X
X
X
X
X
X
X
X
X
X
X
X
10
6
6
7
40
SHOP
Small Group Market Analysis
This is a representative sample of the Carrier's plans and rates.
It is not intended to promote one Carrier over another Carrier
41
Small Group Market
Company ( * Trading Partners)
Colorado Choice *
Colorado HealthOP *
Anthem *
Kaiser Permanente *
Rocky Mountain Health Plans *
SeeChange *
UnitedHealthcare
Grand Total
42
Level of
Coverage*
Bronze
Gold
Silver
Bronze
Gold
Silver
Bronze
Gold
Platinum
Silver
Bronze
Gold
Silver
Off the Market Place
3
3
6
2
2
2
11
26
2
30
9
15
19
On the Market Place
3
3
4
2
2
2
1
2
2
9
6
9
Grand Total
6
6
10
4
4
4
12
28
2
32
18
21
28
Bronze
Gold
Silver
Bronze
Gold
Silver
12
12
20
5
1
3
12
12
20
1
1
1
24
24
40
6
2
4
Bronze
Gold
Platinum
Silver
12
23
4
44
266
92
12
23
4
44
358
42
Small Group Medical Plans On & Off the Market Place
65% More Plans OFF the Market Place
266
92
Off the Market Place
43
On the Market Place
43
Small Group Market by Carrier
71
58
44 44
43
24
12 10
6 6
4
Off the Market Place
44
9
3
0
On the Market Place
44
Small Group Market by Metal Tier
48% more Bronze Plans
266
69% more Silver Plans
68% more Gold Plans
124
92
82
54
38
28
26
6
Bronze
Silver
Gold
Off the Market Place
45
0
Platinum
Total
On the Market Place
45
Small Group Medical Plans On & Off the
Market Place by Product Type
191
124 67
102
77
42
42
23
23
25
0
0
EPO
HMO
Off the Market Place
46
POS
On the Market Place
PPO
Grand Total
46
SHOP Silver Rate Comparison Plans ON the Market Place
Rates Based on a 27 Year Old
Plans On The Market Place
Colo Springs
Denver
Fort Collins
Company
Plan
Low
High
Low
High
Low
High
Colorado Choice
HMO
$242.50
$253.14
$270.38
$282.24
$328.91
$343.34
CoOpStateWideOne
PPO
$334.70
$334.70
$340.66
$340.66
$373.76
$373.76
CoOpStateWideTwo
PPO
$264.83
$264.83
$269.68
$269.68
$296.58
$296.58
Kaiser Permanente DB
HMO
$251.96
$259.43
Kaiser Permanente N Co
HMO
$239.36
$246.46
Kaiser Permanente S Co
HMO
$277.16
$285.37
Athem / RMHMS
PPO
$278.88
$278.88
$299.93
$299.93
$336.17
$336.17
RMHP HCO
PPO
$288.84
$299.48
$325.78
$337.78
$406.38
$421.35
RMHP CHP Network
HMO
$266.35
$277.32
$300.42
$312.80
$374.74
$390.19
RMHP NWP Network
HMO
$252.42
$262.97
$284.71
$296.60
$355.15
$370.00
RMHP Statewide Network
HMO
$280.28
$292.10
$316.13
$329.46
$394.34
$410.97
SeeChange
PPO
$300.30
$300.30
$320.83
$320.83
$357.09
$357.09
47
47
SHOP Rating Area Comparison Low End Plans
State Wide Carriers Only
Rates Based on a 27 Year Old
Area 1 Area 2
Area 3
Area 4 Area 5
Area 6 Area 7 Area 8 Area 9 Area 10 Area 11
Boulder CoSpr
Denver
Ft
Grand
Collins Junction Greeley Pueblo
Plans ON The Market Place
Low
Low
Low
Low
Low
Low
Low
S East
N East
West
Resort
Low
Low
Low
Low
Company
Plan
COOP (Metro)
PPO $332.11 $334.70 $340.66 $373.76 $442.54 $361.38 $366.28 $350.65 $447.22 $481.48 $578.38
43%
COOP (State)
PPO $262.73 $264.83 $269.68 $296.58 $350.87 $286.55 $290.52 $277.80 $354.63 $382.37 $460.78
43%
Athem / RMHMS
PPO $289.09 $278.88 $299.93 $336.17 $307.81 $357.07 $296.12 $302.63 $383.11 $344.71 $422.90
34%
RMHP HCO
PPO $372.81 $288.84 $325.78 $406.38 $288.84 $389.59 $372.81 $356.01 $456.77 $339.22 $470.20
39%
RMHP CHP Network
HMO $343.78 $266.35 $300.42 $374.74 $266.35 $359.26 $343.78 $328.29 $421.20 $312.81 $433.59
39%
RMHP NWP Network
RMHP Statewide
Network
HMO $325.79 $252.42 $284.71 $355.15 $252.42 $340.47 $325.79 $311.12 $399.17 $296.45 $410.91
39%
HMO $361.76 $280.28 $316.13 $394.34 $280.28 $378.05 $361.76 $345.46 $443.23 $329.17 $456.27
39%
SeeChange
PPO $281.05 $300.30 $320.83 $357.09 $349.71 $401.04 $274.31 $401.04 $401.04 $462.00 $462.00
41%
Small Group Silver Plans
48
48
SHOP Rating Area Comparison High End
Plans State Wide Carriers Only
Rates Based on a 27 Year Old
Area 1
Area 2
Area 3
Area 4
Area 5
Area 6
Area 7
Area 8
Area 9
Area 10 Area 11
Boulder
CoSpr
Grand
Denver Ft Collins Junction Greeley
Pueblo
S East
N East
West
Resort
High
High
High
High
High
High
High
Plans ON The Market Place
Company
Plan
High
High
High
High
COOP (Metro)
PPO $332.11 $334.70 $340.66 $373.76 $442.54 $361.38 $366.28 $350.65 $447.22 $481.48 $578.38
43%
COOP (State)
PPO $262.73 $264.83 $269.68 $296.58 $350.87 $286.55 $290.52 $277.80 $354.63 $382.37 $460.78
43%
Athem / RMHMS
PPO $289.09 $278.88 $299.93 $336.17 $307.81 $357.07 $296.12 $302.63 $383.11 $344.71 $422.90
34%
RMHP HCO
PPO $386.52 $299.48 $337.78 $421.35 $299.48 $403.94 $386.52 $369.12 $473.58 $351.71 $487.51
39%
RMHP CHP Network
HMO $357.94 $277.32 $312.80 $390.19 $277.32 $374.06 $357.94 $341.82 $438.56 $325.70 $451.46
39%
RMHP NWP Network
RMHP Statewide
Network
HMO $339.42 $262.97 $296.60 $370.00 $262.97 $354.71 $339.42 $324.13 $415.87 $308.84 $428.10
39%
HMO $377.01 $292.10 $329.46 $410.97 $292.10 $394.00 $377.01 $360.03 $461.92 $343.04 $475.51
39%
SeeChange
PPO $281.05 $300.30 $320.83 $357.09 $349.71 $401.04 $274.31 $401.04 $401.04 $462.00 $462.00
41%
Small Group Silver Plans
49
49
Small Group Market Analysis
65% More Plans OFF the Market Place than ON the Market Place.
266 OFF the Market Place / 92 ON the Market Place
Anthem has 93% more plans OFF the Market Place (58 VS 4)
United HealthCare has 71 plans OFF the Market Place, none ON the Market Place
Plan Types 191 HMO, 102 PPO, 42 POS, 23 EPO
Plans ON the Market Place
Colorado Springs average 25% difference between the lowest & highest price plan
Denver average 30% difference between the lowest & highest price plan
Fort Collins average 47% difference between the lowest & highest price plan
Most C4HCO carriers offer equal rates ON & OFF the Market Place, except KP offers 2% lower rates
for plans ON, SeeChange offer additional plans OFF at 4% lower rate, Anthem for the Silver
tier offers 30 plans OFF & 2 plans ON, the plans OFF are 7% lower & 9% higher
For Statewide carriers, Boulder & COS offer the lower rates & the Resort area the Highest at about 40%
50
50
Individual
Market Analysis
This is a representative sample of the Carrier's plans and rates.
It is not intended to promote one Carrier over another Carrier
51
Individual Market (section 1)
Company
( * Trading Partners)
52
Level of Coverage*
Bronze
Catastrophic
UnitedHealthCare
Gold
All Savers *
Platinum
Silver
Bronze
Cigna *
Gold
Silver
Bronze
Catastrophic
Colorado Choice *
Gold
Silver
Bronze
Catastrophic
Colorado HealthOP *
Gold
Silver
Gold
Denver Health
Medical *
Silver
Bronze
Catastrophic
Anthem *
Gold
Silver
Off the Market
Place
3
3
5
3
1
3
5
2
2
2
6
1
2
6
On the Market
Place
2
1
2
1
3
3
3
5
3
1
3
5
2
2
2
2
2
2
6
1
2
5
Grand Total
2
1
2
1
3
6
6
10
6
2
6
10
4
2
4
4
2
2
12
2
4
11
52
Individual Market (section 2)
Company
( * Trading Partners)
53
Level of Coverage*
Bronze
Catastrophic
Kaiser Permanente *
Gold
Silver
Bronze
Access Health
Gold
Colorado *
Silver
Bronze
Catastrophic
Rocky Mountain
Health Plans*
Gold
Silver
Bronze
Catastrophic
Time Insurance
Gold
Company
Platinum
Silver
Bronze
Catastrophic
Humana *
Gold
Platinum
Silver
Grand Total
Off the Market
Place
9
3
6
9
14
2
2
16
14
2
4
4
8
8
4
1
1
8
159
On the Market
Place
9
3
6
9
2
2
2
20
4
4
24
2
1
1
1
2
150
Grand Total
18
6
12
18
2
2
2
34
6
6
40
14
2
4
4
8
10
5
2
2
10
309
53
Individual Medical Plans On & Off the Market Place
6% More Plans OFF the Market Place
159
150
Off the Market Place
54
On the Market Place
54
Individual Market by Carrier
52
34
32
27 27
22
9
0
11 11
12 12
15 14
6 8
0
4
Off the Market Place
55
6
0
7
0
On the Market Place
55
Individual Market by Metal Tier
159
150
59
49
59 59
23 27
13 13
Catastrophic
5
Bronze
Silver
Off the Market Place
56
Gold
2
Platinum
Total
On the Market Place
56
Individual Medical Plans On & Off the Market
Place by Product Type
175
108
98
77
3
13 16
EPO
10
HMO
Off the Market Place
57
69 39
0 10
POS
On the Market Place
PPO
Grand Total
57
Individual Silver Rate Comparison Plans
ON the Market Place
Rates Based on a 27 Year Old
Plans ON The Market Place
Colo Springs
Company
Plan
United HC / All Savers
Cigna
EPO
PPO
Colorado Choice
HMO
COOP (Metro)
EPO
COOP (State)
Denver Health closed network
PPO
HMO
Denver Health Exp network
HMO
Anthem / HMO Colorado
HMO
$245.78
Anthem / HMO Colorado
HMO
Humana Health Plan
HMO
Kaiser Permanente DB
HMO
Kaiser Permanente N Co
HMO
Kaiser Permanente S Co
HMO
$221.15
$235.14
CO Access / New Ventures
PPO
$340.80
$345.07
$372.33
RMHP CHP Network
HMO
$231.57
$255.07
RMHP Mesa
HMO
$233.91
RMHP NWP Network
HMO
RMHP Statewide Network
PPO
58
Low
Fort Collins
Low
High
$249.10
$293.72
$303.02
$223.78
$223.78
$245.75
$245.75
$257.54
$225.37
$257.54
$225.37
$282.80
$282.80
$261.52
$261.52
$272.66
$262.17
$290.85
$276.48
$306.73
$245.78
$272.66
$262.17
$290.85
$276.48
$306.73
$198.58
$201.44
$205.32
$208.27
$201.04
$213.77
$190.99
$203.08
$377.00
$405.45
$410.53
$261.18
$287.70
$325.80
$358.88
$271.91
$263.83
$306.70
$329.11
$382.58
$224.90
$241.75
$253.67
$272.67
$316.43
$340.14
$243.71
$283.28
$274.88
$319.51
$342.90
$398.56
$216.55
$252.98
High
Denver
$223.42
$252.98
Low
High
$312.14
$260.91
$318.57
$292.65
$241.44
58
Individual Rating Area Comparison Low End
Plans State Wide Carriers Only
Rates Based on a 27 Year Old
Area 1
Area 2
Area 3
Boulder
CoSpr
Denver
Low
Low
Low
Area 4
Area 5
Area 6
Area 7
Area 8
Area 9
Area 10 Area 11
Ft
Grand
Collins Junction Greeley
Pueblo
S East
N East
West
Resort
Low
Low
Low
Low
Low
Plans ON The Market Place
Company
Plan
Low
Low
Low
COOP (State)
PPO
$251.01 $252.98 $257.54 $282.80 $334.44 $273.38 $277.12 $265.17 $338.01 $364.22 $437.62
43%
Anthem / HMO Colorado
HMO
$256.66 $245.78 $262.17 $276.48 $294.46 $293.76 $290.97 $289.39 $368.04 $330.52 $406.89
40%
Anthem / HMO Colorado
HMO
$256.66 $245.78 $262.17 $276.48 $294.46 $293.76 $290.97 $289.39 $368.04 $330.52 $406.89
40%
CO Access / New Ventures PPO
$376.31 $340.80 $372.33 $405.45 $412.33 $408.28 $310.43 $359.22 $419.18 $484.22 $540.27
43%
RMHP CHP Network
HMO
$298.88 $231.57 $261.18 $325.80 $231.57 $312.34 $298.88 $285.41 $366.19 $271.95 $376.97
39%
RMHP Mesa
HMO
$301.91 $233.91 $263.83 $329.11 $233.91 $315.51 $301.91 $288.32 $369.91 $274.71 $380.79
39%
RMHP NWP Network
HMO
$290.28 $224.90 $253.67 $316.43 $224.90 $303.35 $290.28 $277.21 $355.66 $264.13 $366.12
39%
RMHP Statewide Network PPO
$314.56 $243.71 $274.88 $342.90 $243.71 $328.73 $314.56 $300.39 $385.40 $286.22 $396.73
39%
Individual Silver Plans
59
59
Individual Rating Area Comparison High End
Plans State Wide Carriers Only
Rates Based on a 27 Year Old
Area 1
Area 2
Area 3
Boulder
CoSpr
Denver
High
High
High
Area 4
Area 5
Area 6
Area 7
Area 8
Area 9
Area 10 Area 11
Ft
Grand
Collins Junction Greeley
Pueblo
S East
N East
West
Resort
High
High
High
High
High
Plans ON The Market Place
Company
Plan
COOP (State)
PPO
$251.01 $252.98 $257.54 $282.80 $334.44 $273.38 $277.12 $265.17 $338.01 $364.22 $437.62
43%
Anthem / HMO Colorado
HMO
$284.74 $272.66 $290.85 $306.73 $326.67 $325.91 $322.80 $321.05 $408.30 $366.67 $451.41
40%
Anthem / HMO Colorado
HMO
$284.74 $272.66 $290.85 $306.73 $326.67 $325.91 $322.80 $321.05 $408.30 $366.67 $451.41
40%
CO Access / New
Ventures
PPO
$381.02 $345.07 $377.00 $410.53 $417.50 $413.39 $314.32 $363.72 $424.43 $490.29 $547.04
43%
RMHP CHP Network
HMO
$329.22 $255.07 $287.70 $358.88 $255.07 $344.05 $329.22 $314.39 $403.36 $299.56 $415.23
39%
RMHP Mesa
HMO
$350.96 $271.91 $306.70 $382.58 $271.91 $366.78 $350.96 $335.15 $430.02 $319.35 $442.65
39%
RMHP NWP Network
HMO
$312.02 $241.75 $272.67 $340.14 $241.75 $326.07 $312.02 $297.97 $382.30 $283.91 $393.54
39%
RMHP Statewide Network PPO
$365.63 $283.28 $319.51 $398.56 $283.28 $382.10 $365.63 $349.16 $447.98 $332.69 $461.15
39%
60
High
High
Individual Silver Plans
High
60
Individual Market Analysis
6% More Plans OFF the Market Place than ON the Market Place.
159 OFF the Market Place / 150 ON the Market Place
RMHP has 35% more plans ON the Market Place(52 VS 34)
Humana has 68% more plans OFF the Market Place (22 VS 7)
Plans ON & OFF the Market Place
Colorado Springs average 40% difference between the lowest & highest price plan
Denver average 48% difference between the lowest & highest price plan
Fort Collins average 53% difference between the lowest & highest price plan
Most C4HCO carriers offer equal rates ON & OFF the Market Place, except KP on average offers 3% lower rates
for plans ON.
For Statewide carriers, Boulder & COS offer the lower rates & the Resort area the Highest at about 40%
61
61
Dental Small Group
Market Analysis
This is a representative sample of the Carrier's plans and rates.
It is not intended to promote one Carrier over another Carrier
62
Dental Small Group Market
Off the Market On the Market
Company ( * Trading Partners)
Best Life Insurance Company *
Delta Dental / Colorado Dental *
Dentegra Insurance Company *
Metropolitan Life Insurance Company *
Premier Access *
Renaissance Life and Health IC of America
Anthem / Rocky Mountain
Hospital and Medical Serv. *
See Change Insurance Company
The Guardian Life *
Grand Total
63
Grand Total
Level of Coverage*
High
3
3
6
Low
3
3
6
High
119
3
122
Low
3
1
4
High
3
3
6
Low
3
3
6
High
2
2
4
Low
2
2
4
Low
3
3
6
High
1
1
Low
1
1
High
6
6
12
Low
9
7
16
High
1
1
Low
8
8
High
4
4
8
Low
7
178
5
45
12
223
63
Small Group Dental Plans On & Off the Market Place
75% More Plans OFF the Market Place
178
45
Delta Dental has 97% More Plans OFF the Market Place
64
64
Small Group Dental Plans
On & Off the Market Place by Product Type
223
178
160
139
63
39
45
21
Off the Market Place
On the Market Place
High
65
24
Low
Grand Total
Total
65
Small Group Market by Carrier
22
17
13
11
9
9
6 6
6 6
4
4 4
3 3
2
0
Off the Market Place
66
0
On the Market Place
66
Dental Individual
Market Analysis
This is a representative sample of the Carrier's plans and rates.
It is not intended to promote one Carrier over another Carrier
67
Dental Individual Market
Company
Best Life Insurance Company
CIGNA
Delta Dental / Colorado Dental
Dentegra Insurance Company
Premier Access
Renaissance Life and Health IC of America
Anthem
Grand Total
68
Level of
Coverage*
High
Off the
Market
On the
Market
Grand Total
3
3
6
Low
3
3
6
Low
1
2
3
High
3
3
6
Low
1
2
3
High
3
3
6
Low
3
3
6
Low
3
3
6
High
2
2
Low
2
2
High
2
2
Low
2
2
28
22
50
68
Individual Dental Plans On & Off the Market Place
18% More Plans OFF the Market Place
28
22
Off the Market Place
On the Market Place
Small Group has 77% More Plans than the Individual Market
69
69
Individual Market by Carrier
6
6
6
6
5
4
4
3
4
3
2
1
0
Off the Market Place
70
0
On the Market Place
70
Individual Dental Plans
ON & OFF the Market Place by Product Type
50
28
28
22
13
15
Off the Market Place
13
9
On the Market Place
High
71
22
Low
Grand Total
Total
71
Carriers Benefit Comparison
By Metal Tier
This is a representative sample of the Carrier's plans and rates.
It is not intended to promote one Carrier over another Carrier
72
Cost-Sharing and Metal Tiers
ACA Precious Metal Tiers
In general, lower
member cost-sharing
and higher premiums
In general, higher
member cost-sharing
and lower premiums
73
Plan Tier
Actuarial
Value
Platinum
90%
Gold
80%
Silver
70%
Bronze
60%
Actuarial value
percentages represent
how much of a typical
population’s medical
spending a health
insurance plan would
cover.
73
Benefit Comparison By Metal Tier
Access Health Colorado Sample
Benefits
Ded Individual
Ded Family
OOPMax Ind
OOPMax Family
Bronze PPO
$5,000
$10,000
$6,350
$12,700
$10,000
$20,000
$12,700
$25,400
Primary Care
40% Coin After Ded
50% Coin After Ded
Specialist visit
40% Coin After Ded
Prevention visit
Access Health Colorado
Silver PPO
$4,000
$8,000
$6,350
$12,700
Gold PPO
$8,000
$16,000
$12,700
$25,400
$2,000
$4,000
$4,000
$8,000
$4,000
$8,000
$8,000
$16,000
$25 Copay
50% Coin After Ded
$10 Copay
40% Coin After Ded
50% Coin After Ded
$50 Copay
50% Coin After Ded
40% Coin After Ded
No Charge $0 Copay
50% Coin After Ded
No Charge $0 Copay
50% Coin After Ded
$20 Copay
No Charge $0
Copay
Diagnostic Test
40% Coin After Ded
50% Coin After Ded
30% Coin After Ded
50% Coin After Ded
20% Coin After Ded
40% Coin After Ded
Imaging
40% Coin After Ded
50% Coin After Ded
30% Coin After Ded
50% Coin After Ded
20% Coin After Ded
40% Coin After Ded
Generic Drugs
40% Coin After Ded
50% Coin After Ded
$10 Copay
50% Coin After Ded
$5 Copay
40% Coin After Ded
Preferred Drugs
40% Coin After Ded
50% Coin After Ded
$20 Copay
50% Coin After Ded
$10 Copay
40% Coin After Ded
Non-Preferred
40% Coin After Ded
50% Coin After Ded
$40 Copay
50% Coin After Ded
$15 Copay
40% Coin After Ded
Specialty Drugs
40% Coin After Ded
50% Coin After Ded
$30
50% Coin After Ded
20%
40% Coin After Ded
Facility Outpatient
40% Coin After Ded
50% Coin After Ded
30% Coin After Ded
50% Coin After Ded
20% Coin After Ded
40% Coin After Ded
Facility Inpatient
Emergency visit
40% Coin After Ded
40% Coin After Ded
50% Coin After Ded
40% Coin After Ded
30% Coin After Ded
$250 Copay
50% Coin After Ded
$250 Copay
20% Coin After Ded
$250 Copay
40% Coin After Ded
$250 Copay
Emergency Trans
40% Coin After Ded
50% Coin After Ded
30% Coin After Ded
50% Coin After Ded
20% Coin After Ded
40% Coin After Ded
Urgent Care
40% Coin After Ded
50% Coin After Ded
Premium
$302.59
% increase Lowest Plan
74
30% Coin After Ded 50% Coin After Ded
$386.19
22%
40% Coin After Ded
20% Coin After Ded 40% Coin After Ded
$448.94
33%
74
Benefit Comparison By Metal Tier
Anthem BC/BS Sample
Anthem / Blue Cross Blue Shield /HMO Colorado
Benefits
Catastrophic DirectAccess Bronze DirectAccess cabz Silver DirectAccess cbma Gold DirectAccess ccab
Ded Individual
$6,530
$5,750
$1,250
$750
Ded Family
$12,700
$11,500
$2,500
$1,500
OOPMax Ind
$6,530
$6,350
$6,350
$6,000
OOPMax Family
$12,700
$12,700
$12,700
$12,000
Primary Care
3 OV / 0% Coin After Ded
435 Copay (2V) / 30% Coin $35 Copay (2V) / 35% Coin
$30 Copay
Specialist visit
0% Coin After Ded
30% Coin After Ded
35% Coin After Ded
0% Coin After Ded
Prevention visit
No Charge $0 Copay
No Charge $0 Copay
No Charge $0 Copay
No Charge $0 Copay
Diagnostic Test
0% Coin After Ded
30% Coin After Ded
35% Coin After Ded
0% Coin After Ded
Imaging
0% Coin After Ded
30% Coin After Ded
35% Coin After Ded
0% Coin After Ded
Generic Drugs
0% Coin After Ded
30% Coin After Ded
$15 Copay
$15 Copay
Preferred Drugs
0% Coin After Ded
30% Coin After Ded
$40 Copay
$40 Copay
Non-Preferred
0% Coin After Ded
30% Coin After Ded
35% Coin After Ded
0% Coin After Ded
Specialty Drugs
0% Coin After Ded
30% Coin After Ded
35% Coin After Ded
0% Coin After Ded
Facility Outpatient
0% Coin After Ded
30% Coin After Ded
35% Coin After Ded
0% Coin After Ded
Facility Inpatient
0% Coin After Ded
$500 Copay /30% Coin AD $500 Copay /35% Coin AD $500 Copay / 0% Coin AD
Emergency visit
0% Coin After Ded
$200 Copay / 30% Coin AD $200 Copay / 35% Coin AD $200 Copay / 0% Coin AD
Emergency Trans
0% Coin After Ded
Urgent Care
0% Coin After Ded
Premium
$188.27
% increase Catastrophic Plan
75
30% Coin After Ded
35% Coin After Ded
$50 Copay / 30% Coin AD $50 Copay / 35% Coin AD
0% Coin After Ded
$50 Copay / 0% Coin AD
$221.81
$291.12
$372.82
15%
35%
50%
No Rx Deductible
75
Benefit Comparison By Metal Tier
Cigna Plan Sample
Cigna
Benefits
myCigna Health Flex 5500
myCigna Health Flex 1500
myCigna Health Flex 1900
Ded Individual
$5,500
$12,500
$1,500
$12,500
$1,900
$12,500
Ded Family
$11,000
$25,000
$3,000
$25,000
$3,800
$25,000
OOPMax Ind
$6,350
$25,000
$6,350
$25,000
$6,350
$25,000
OOPMax Family
$12,700
$50,000
$12,700
$50,000
$12,700
$50,000
Primary Care
1-2 $30 Copay / 40% C A D
50% Coin After Ded
1-2 $30 Copay / 40% C A D 50% Coin After Ded No Charge $0 Copay 50% Coin After Ded
Specialist visit
1-2 $60 Copay / 40% C A D
50% Coin After Ded
1-2 $60 Copay / 40% C A D 50% Coin After Ded No Charge $0 Copay 50% Coin After Ded
Prevention visit
No Charge $0 Copay
No Charge $0 Copay
No Charge $0 Copay
50% Coin After Ded No Charge $0 Copay 50% Coin After Ded
Diagnostic Test
40% Coin After Ded
50% Coin After Ded
30% Coin After Ded
50% Coin After Ded No Charge $0 Copay 50% Coin After Ded
Imaging
40% Coin After Ded
50% Coin After Ded
30% Coin After Ded
50% Coin After Ded No Charge $0 Copay 50% Coin After Ded
$4 Copay
Not Covered
$4 Copay
Not Covered
No Charge $0 Copay
Not Covered
Non-Preferred G
40% Coin After Ded
Not Covered
$20 Copay
Not Covered
No Charge $0 Copay
Not Covered
Preferred Drugs
40% Coin After Ded
Not Covered
$60 Copay
Not Covered
No Charge $0 Copay
Not Covered
Non-Preferred
50% Coin After Ded
Not Covered
50% Coin After Ded
Not Covered
50% Coin After Ded
Not Covered
Specialty Drugs
40% Coin After Ded
Not Covered
40% Coin After Ded
Not Covered
No Charge $0 Copay
Not Covered
Facility Outpatient
40% Coin After Ded
50% Coin After Ded
30% Coin After Ded
50% Coin After Ded No Charge $0 Copay 50% Coin After Ded
Facility Inpatient
40% Coin After Ded
50% Coin After Ded
30% Coin After Ded
50% Coin After Ded No Charge $0 Copay 50% Coin After Ded
Emergency visit
40% Coin After Ded
40% Coin After Ded
30% Coin After Ded
50% Coin After Ded No Charge $0 Copay 50% Coin After Ded
Emergency Trans
40% Coin After Ded
50% Coin After Ded
30% Coin After Ded
50% Coin After Ded No Charge $0 Copay 50% Coin After Ded
$75 Copay
50% Coin After Ded
$75 Copay
50% Coin After Ded No Charge $0 Copay 50% Coin After Ded
Generic Drugs
Urgent Care
Premium
$238.68
% increase Lowest Plan
76
$270.62
$312.43
12%
24%
76
Benefit Comparison By Metal Tier
Colorado Choice Health Plan Sample
Colorado Choice Health Plan
Benefits
Ded Individual
Ded Family
OOPMax Ind
OOPMax Family
Primary Care
Specialist visit
Prevention visit
Diagnostic Test
Imaging
Generic Drugs
Preferred Drugs
Non-Preferred
Specialty Drugs
Facility Outpatient
Facility Inpatient
Emergency visit
Emergency Trans
Urgent Care
Premium
Bronze Choice 3000/50
$3,000
$6,000
$6,350
$12,700
50% Coin After Ded
50% Coin After Ded
No Charge $0 Copay
50% Coin After Ded
50% Coin After Ded
$25 Copay
50% Coin After Ded
50% Coin After Ded
50% Coin After Ded
50% Coin After Ded
50% Coin After Ded
50% Coin After Ded
50% Coin After Ded
50% Coin After Ded
$206.08
% increase Catastrophic Plan
77
Silver Choice 2000/Copay
$2,000
$4,000
$6,350
$12,700
$20 Copay
$40 Copay
No Charge $0 Copay
40% Coin After Ded
$150 Copay
$15 Copay
$40 Copay
$60 Copay
$60 Copay
40% Coin After Ded
40% Coin After Ded
$150 Copay After Ded
$100 Copay After Ded
40% Coin After Ded
$261.20
Gold Choice 1500/20
$1,500
$3,000
$4,000
$8,000
$15 Copay
$25 Copay
No Charge $0 Copay
20% Coin After Ded
20% Coin After Ded
$10 Copay
$35 Copay
$60 Copay
20% Coin Ded Waived
20% Coin After Ded
20% Coin After Ded
$150 Copay
20% Coin After Ded
20% Coin After Ded
$292.59
21%
30%
77
Benefit Comparison By Metal Tier
Colorado HealthOP Plan Sample
Colorado HealthOP
Benefits
HealthOP Bear EPO
HealthOP Bison EPO
HealthOP Bighorn EPO
Ded Individual
$5,500
$2,600
$1,000
Ded Family
$11,000
$5,200
$2,000
OOPMax Ind
$6,350
$6,000
$3750 / $3250
OOPMax Family
$12,700
$12,000
$7500 / $6500
Primary Care
1st Free / 50% Coin After Ded
1st Free / 40% Coin After Ded
1st Free / $30 Copay
Primary Care Enhanced
1st Free / 50% Coin After Ded
$30 Copay
1st Free / $20 Copay
Specialist visit
50% Coin After Ded
40% Coin After Ded
$60 Copay
Specialist Enhanced
50% Coin After Ded
$60 Copay
$40 Copay
Prevention visit
No Charge $0 Copay
No Charge $0 Copay
No Charge $0 Copay
Diagnostic Test
50% Coin After Ded
40% Coin After Ded
35% Coin After Ded
Imaging
50% Coin After Ded
40% Coin After Ded
35% Coin After Ded
Generic Drugs
$15 Copay / After Ded
$15 Copay
$15 Copay
Preferred Drugs
50% Coin After Ded
$40 Copay
$30 Copay
Non-Preferred
50% Coin After Ded
40% Coin Ded Waived
35% Coin Ded Waived
Specialty Drugs
50% Coin After Ded
40% Coin Ded Waived
35% Coin Ded Waived
Facility Outpatient
50% Coin After Ded
40% Coin After Ded
35% Coin After Ded
Facility Inpatient
50% Coin After Ded
40% Coin After Ded
35% Coin After Ded
Emergency visit
50% Coin After Ded
$500 Copay
$350 Copay
Emergency Trans
50% Coin After Ded
40% Coin After Ded
35% Coin After Ded
Urgent Care
50% Coin After Ded
40% Coin After Ded
35% Coin After Ded
$173.01
$232.10
$276.42
25%
37%
Premium
% increase Catastrophic Plan
78
78
Benefit Comparison By Metal Tier
Denver Health Medical Sample
Denver Health Medical / ELEVATE
Benefits
ELEVATE Silver Basic HMO ELEVATE Gold Basic HMO ELEVATE Silver Expanded HMO ELEVATE Gold Expanded HMO
Ded Individual
$2,500
$1,600
$2,500
$1,600
Ded Family
$5,000
$3,200
$5,000
$3,200
OOPMax Ind
$6,250
$5,000
$6,250
$5,000
OOPMax Family
$12,500
$10,000
$12,500
$10,000
Primary Care
$40 Copay
$15 Copay
$40 Copay
$15 Copay
Specialist visit
$65 Copay
$25 Copay
$65 Copay
$25 Copay
Prevention visit
No Charge $0 Copay
No Charge $0 Copay
No Charge $0 Copay
No Charge $0 Copay
Diagnostic Test
25% Coin After Ded
10% Coin After Ded
25% Coin After Ded
10% Coin After Ded
Imaging
25% Coin After Ded
10% Coin After Ded
25% Coin After Ded
10% Coin After Ded
Generic Drugs
$20 Copay
$10 Copay
$20 Copay
$10 Copay
Preferred Drugs
$45 Copay
$35 Copay
$45 Copay
$35 Copay
Non-Preferred
$80 Copay
$60 Copay
$80 Copay
$60 Copay
Specialty Drugs
$80 Copay
$60 Copay
$80 Copay
$60 Copay
Facility Outpatient 25% Coin After Ded
10% Coin After Ded
25% Coin After Ded
10% Coin After Ded
Facility Inpatient
25% Coin After Ded
10% Coin After Ded
25% Coin After Ded
10% Coin After Ded
Emergency visit
$250 Copay
$150 Copay
$250 Copay
$150 Copay
Emergency Trans
25% Coin After Ded
10% Coin After Ded
25% Coin After Ded
10% Coin After Ded
Urgent Care
$125 Copay
$75 Copay
$125 Copay
$75 Copay
Premium
$233.76
$269.58
$271.25
$269.58
% increase Catastrophic Plan
79
13%
14%
13%
79
Benefit Comparison By Metal Tier
Humana Sample
Humana
Benefits
Bronze 4850/6350 HMO
Silver 4600/6300 HMO
Gold 2500/3500 HMO
Platinum 1000/1500 HMO
Ded Individual
$4,850
$4,600
$2,500
$1,000
Ded Family
$9,700
$9,200
$5,000
$2,000
Rx Ded Individual
$1,500
$1,500
$500
$500
Rx Ded Family
$3,000
$3,000
$1,000
$1,000
OOPMax Ind
$6,350
$6,300
$3,500
$1,500
OOPMax Family
$12,700
$12,600
$7,000
$3,000
Primary Care
$50 Copay
$25 Copay
$25 Copay
$25 Copay
Specialist visit
$75 Copay
$35 Copay
$35 Copay
$35 Copay
Prevention visit
No Charge $0 Copay
No Charge $0 Copay
No Charge $0 Copay
No Charge $0 Copay
Diagnostic Test
20% Coin After Ded
20% Coin After Ded
20% Coin After Ded
20% Coin After Ded
Imaging
20% Coin After Ded
20% Coin After Ded
20% Coin After Ded
20% Coin After Ded
$28 Copay
$17 Copay
$8 Copay
$8 Copay
Preferred Drugs
$75 Copay After Ded
$50 Copay After Ded
$20 Copay After Ded
$20 Copay After Ded
Non-Preferred
50% Coin After Ded
50% Coin After Ded
35% Coin After Ded
35% Coin After Ded
Specialty Drugs
50% Coin After Ded
50% Coin After Ded
35% Coin After Ded
35% Coin After Ded
Facility Outpatient
20% Coin After Ded
20% Coin After Ded
20% Coin After Ded
20% Coin After Ded
Facility Inpatient
20% Coin After Ded
20% Coin After Ded
20% Coin After Ded
20% Coin After Ded
Emergency visit
20% Coin After Ded
20% Coin After Ded
20% Coin After Ded
20% Coin After Ded
Emergency Trans
20% Coin After Ded
20% Coin After Ded
20% Coin After Ded
20% Coin After Ded
$100 Copay
$50 Copay
$50 Copay
$50 Copay
$202.41
$212.96
$242.90
$273.85
5%
17%
26%
Generic Drugs
Urgent Care
Premium
% increase Catastrophic Plan
80
80
Benefit Comparison By Metal Tier
Kaiser Permanente Plan Sample
Kaiser Permanente
Benefits
KP CO Bronze 4500/50
KP CO Silver 2500/30
KP CO Gold 1000/20
Ded Individual
$4,500
$2,500
$1,000
Ded Family
$9,000
$5,000
$2,000
OOPMax Ind
$6,350
$6,350
$6,350
OOPMax Family
$12,700
$12,700
$12,700
Primary Care
$50 Copay
$30 Copay
$20 Copay
Specialist visit
$70 Copay
$50 Copay
$40 Copay
Prevention visit
No Charge $0 Copay
No Charge $0 Copay
No Charge $0 Copay
Diagnostic Test
20% Coin After Ded
30% Coin After Ded
20% Coin After Ded
Imaging
$500 Copay
$300 Copay
$150 Copay
Generic Drugs
$25 Copay
$15 Copay
$10 Copay
Preferred Drugs
45% Coin Ded Waived
$45 Copay
$35 Copay
Non-Preferred
50% Coin Ded Waived
30% Coin Ded Waived
20% Coin Ded Waived
Specialty Drugs
50% Coin Ded Waived
30% Coin Ded Waived
20% Coin Ded Waived
Facility Outpatient
20% Coin After Ded
30% Coin After Ded
20% Coin After Ded
Facility Inpatient
20% Coin After Ded
30% Coin After Ded
20% Coin After Ded
Emergency visit
20% Coin After Ded
$400 Copay
$250 Copay
Emergency Trans
20% Coin After Ded
30% Coin After Ded
20% Coin After Ded
$100 Copay
$75 Copay
$75 Copay
$193.68
$214.79
$244.82
10%
21%
Urgent Care
Premium
% increase Catastrophic Plan
81
81
Benefit Comparison By Metal Tier
Rocky Mountain Health Plan Sample
Rocky Mountain Health Plan
Benefits
NW Bronze $4500/$55 HMO
NW Silver $2500/$40 HMO
Gold PPO $500/Copay $35
Ded Individual
$4,500
$2,500
$500
$1,000
Ded Family
$9,000
$5,000
$1,000
$2,000
Rx Ded Individual
N/A
$500
N/A
N/A
Rx Ded Family
N/A
$1,000
N/A
N/A
OOPMax Ind
$6,350
$6,350
$4,000
$8,000
OOPMax Family
$12,700
$12,700
$8,000
$16,000
$55 Copay
$40 Copay
$35 Copay
50% Coin After Ded
Specialist visit
40% Coin After Ded
$55 Copay
$50 Copay
50% Coin After Ded
Prevention visit
No Charge $0 Copay
No Charge $0 Copay
No Charge $0 Copay
No Charge $0 Copay
Diagnostic Test
40% Coin After Ded
30% Coin After Ded
20% Coin After Ded
50% Coin After Ded
Imaging
40% Coin After Ded
30% Coin After Ded
20% Coin After Ded
50% Coin After Ded
Primary Care
Generic Drugs
$20 Copay
$15 Copay
$15 Copay
Not Covered
Preferred Drugs
40% Coin After Ded
30% Coin After Ded
20%
Not Covered
Non-Preferred
40% Coin After Ded
40% Coin After Ded
40%
Not Covered
Specialty Drugs
50% Coin After Ded
40% Coin After Ded
40%
Not Covered
Facility Outpatient
40% Coin After Ded
30% Coin After Ded
20% Coin After Ded
50% Coin After Ded
Facility Inpatient
40% Coin After Ded
30% Coin After Ded
20% Coin After Ded
50% Coin After Ded
Emergency visit
$350 Copay
$250 Copay
20% Coin After Ded
20% Coin After Ded
Emergency Trans
40% Coin After Ded
30% Coin After Ded
20% Coin After Ded
20% Coin After Ded
Urgent Care
40% Coin After Ded
30% Coin After Ded
20% Coin After Ded
50% Coin After Ded
$233.31
$263.11
$365.79
11%
36%
Premium
% increase Lowest Plan
82
82
Benefit Comparison By Metal Tier
UnitedHealthcare Sample
Benefits
Ded Individual
Ded Family
Ded Rx Ind
Ded Rx Family
OOPMax Ind
OOPMax Family
Primary Care
Specialist visit
Prevention visit
Diagnostic Test
Imaging
Generic Drugs
Preferred Drugs
Non-Preferred
Specialty Drugs
Facility Outpatient
Facility Inpatient
Emergency visit
Emergency Trans
Urgent Care
Premium
Catastrophic Plan
$6500 per person
N/A
N/A
N/A
$6,350
$12,700
3 OV per person
No Charge after Ded
No Charge $0 Copay
No Charge after Ded
No Charge after Ded
No Charge after Ded
No Charge after Ded
No Charge after Ded
No Charge after Ded
No Charge after Ded
No Charge after Ded
No Charge after Ded
No Charge after Ded
No Charge after Ded
$288.49
% increase Catastrophic Plan
83
UnitedHealthcare / All Savers Individual Plans
Copay Bronze Plan
Copay Silver Plan C
Copay Gold Plan C
$5500 per person
$5000 per person
$1500 per person
N/A
N/A
N/A
N/A
$500 per person T2-4
$150 per person T2-4
N/A
N/A
N/A
$6,350
$6,350
$3,200
$12,700
$12,700
$6,400
$50 Copay / 20% Coin
$20 Copay / 20% Coin
$10 Copay / 10% Coin
$100 Copay / 20% Coin $60 Copay / 20% Coin $40 Copay / 20% Coin
No Charge $0 Copay
No Charge $0 Copay
No Charge $0 Copay
20% Coin
20% Coin
20% Coin
20% Coin
20% Coin
20% Coin
20% Coin
$15 Copay
$15 Copay
20% Coin
$40 Copay/After Ded
$35 Copay/After Ded
20% Coin
$80 Copay/After Ded
$70 Copay/After Ded
20% Coin
25% of nego. Rate / AD $250 Copay/After Ded
20% Coin
20% Coin
20% Coin
20% Coin
20% Coin
20% Coin
20% Coin
20% Coin
$300 Copay
20% Coin
20% Coin
$300 Copay
20% Coin
20% Coin
$75 Copay
$322.22
$343.75
$395.19
$20 Copay / 10% Coin
No Charge $0 Copay
10% Coin
10% Coin
$10 Copay
$35 Copay
$60 Copay
$250 Copay
10% Coin
10% Coin
$250 Copay
10% Coin
$75 Copay
$470.62
10%
$35 Copay / 20% Coin
Copay Plan Platinum
$500 per person
N/A
N/A
N/A
$1,500
$3,000
16%
27%
39%
83
Carrier Specific Key Points
& Service Area
This is a representative sample of the Carrier's Key Points and Service Area.
It is not intended to promote one Carrier over another Carrier
84
Colorado Rating Areas by County
• Colorado has 11 rating areas based on varies counties
o Rating Area 1 & 2 have the lowest rates & Rating Area 11 the highest
(rates average about 40% difference)
o Some zip codes will cross multiple counties
• If your coverage is through your employer, the rate is based on the employers
zip code & county
85
Rating Area 1
Rating Area 2
Rating Area 3
Rating Area 4
Rating Area 5
Rating Area 6
Rating Area 7
Rating Area 8
Rating Area 9
Rating Area 10
Rating Area 11
Boulder
Boulder County
Colo Springs
El Paso
Teller
Denver
Adams
Arapahoe
Broomfield
Clear Creek
Denver
Douglas
Elbert
Gilpin
Jefferson
Park
Fort Collins
Larimer
Grand Junction
Mesa
Greeley
Weld
Pueblo
Pueblo
SouthEast
Baca
Bent
Cheyenne
Crowley
Custer
Frmont
Huerfano
Kiowa
Kit Carson
Las Animas
Lincoln
Mineral
Otero
Prowers
Alamosa
Chaffee
Conejos
Costilla
Rio Grande
Saguache
NorthEast
Logan
Morgan
Phillips
Sedwick
Washington
Yuma
West
Archuleta
Delta
Dolores
Grand
Gunnison
Hinsdale
Jackson
La Plata
Lake
Moffat
Montezuma
Montrose
Ouray
Rio Blanco
Routt
San Juan
San Miguel
Resort
Eagle
Garfield
Pitkin
Summit
85
Colorado Rating Area Map
Rating Area 1 = Boulder ( Counties 1 )
Rating Area 2 = Colorado Springs ( Counties 2 )
Rating Area 3 = Denver ( Counties 10 )
Rating Area 4 = Fort Collins ( Counties 1 )
Rating Area 5 = Grand Junction ( Counties 1 )
Rating Area 6 = Greeley ( Counties 1 )
Rating Area 7 = Pueblo ( Counties 1 )
Rating Area 8 = South East ( Counties 20 )
Rating Area 9 = North East ( Counties 6 )
Rating Area 10 = West ( Counties 17 )
Rating Area 11 = Resort ( Counties 4 )
4
1
10
6
3
11
5
2
10
86
9
7
8
8
86
Access Health Colorado / New Health Ventures
Individual Market
Unique Offerings and Programs
•
•
•
•
•
•
•
Statewide PPO – see any provider in Colorado
More specialists
Behavioral health providers and primary care providers have the
same low copay
Local call center
Integrated care with complete health and wellness programs
Parent company, Colorado Access has more than 18 years of
experience as a public insurance carrier
Many avenues for member input and engagement – we listen to you
Service Area
• Statewide Coverage
87
87
Anthem BlueCross and BlueShield
Individual & Small Group Market
Unique Offerings and Programs
Once you’re a member, these tools and services will help put you in control:
• 24/7 NurseLine: access to a registered nurse who’s trained to help you
make informed health care decisions.
• Find a Doctor: helps you find doctors, hospitals, pharmacies and
specialists in your area.
• Zagat Health Survey: see what other patients have said about doctors and
hospitals before you use them.
Service Area
• Statewide Coverage
88
88
Cigna
Individual Market
Unique Offerings and Programs
• 24/7 Call Center making Cigna the first national health service company to
offer customer service call center hours 24 hours a day, 7 days a week to
answer questions at any time.
• Online Tools to compare the cost and quality of medications, medical services,
and hospital care.
• Health Information Line Staffed by Trained Nurses who can offer detailed
answers to health questions, available 24 hours a day, 7 days a week.
• Door-to-Door Home Delivery Pharmacy that offers both convenience and
reduced costs for prescription drugs.
• Healthy Rewards® Discount Program for weight management and nutrition
products, tobacco cessation, fitness club memberships and more.
Service Area
• NO Statewide Coverage, limited 6 counties rating area 3
89
89
Cigna Individual Service Area
Cigna
Cigna
Cigna
Cigna
Cigna
90
90
Colorado Choice Health Plans
Individual & Small Group Market
Unique Offerings and Programs
• Care Management Programs with Nurse Navigators to help guide patients towards
their health care goals
• Health and Wellness programs and educational materials that are member centric
• Best Practice Protocols developed by physicians and nationally recognized provider
organizations
Pilot programs:
• Prometheus – provides physicians with individually-based patient information
designed to avoid unnecessary costs and improve health outcomes
• Engaged Benefit Design – engages both the patient and provider in shared decision
making and provides incentives for the use of high value, evidence-based services
• Colorado Primary Care Initiative – provides primary care physicians with data and
tools to improve the health of their patient populations
Service Area:
• No Statewide, 30 counties & 6 rating areas
91
91
Colorado Choice Health Plans Service Area
CO Choice
CO Choice
CO Choice CO Choice
CO Choice
CO Choice
CO Choice
CO Choice
CO Choice
CO Choice
CO Choice
CO Choice
CO Choice
CO Choice
CO Choice
CO Choice
CO Choice
CO Choice
CO Choice
CO Choice
CO Choice
CO Choice
CO Choice
CO Choice
92
CO Choice
CO Choice
CO Choice
CO Choice
CO Choice
CO Choice
92
Colorado HealthOP
Individual & Small Group Market
Unique Offerings and Programs
Colorado HealthOP offers incentives for preventive care. That means that our
members receive rewards for doing a few simple screenings each year. Rewards
may include money in health incentive accounts, smaller out-of-pocket maximums
or credits toward deductibles.
As a cooperative (CO-OP), Colorado HealthOP also offers members the chance to
affect what is covered in their benefit structure. Starting in 2014, members will be
elected to the CO-OP’s board of directors. Board members will guide the future of
the CO-OP, including what is covered in benefit plans.
Service Area:
• Statewide coverage for PPO plans
• EPO accesses to Central Metro Network – limited 17 counties & 7 rating areas
93
93
Colorado HealthOP
Central Metro Network (EPO)
COOP
COOP
COOP
COOP
COOP
COOP
COOP
COOP
COOP
COOP
COOP
COOP
COOP
COOP
COOP
COOP
COOP
94
94
Denver Health Medical Plan / ELEVATE
Individual Market
95
Unique Offerings and Programs
• Mom’s To Be: A program offering incentives to encourage pregnant women to
get prenatal care. Incentives include two months of diapers, an umbrella
stroller, and a car seat.
• Baby’s First Year: Preventive care is especially important during a child’s first
year of life. This is when vaccinations are given and growth patterns can be
watched. This program encourages this care by offering incentives such as a
baby monitor, diapers and a play gym.
• Take Control Of Your Health: An extensive health and wellness program that
includes classes on general health topics, living with chronic diseases, and
Cooking Matters, a hands-on healthy cooking class. In addition, we also offer a
shopping class — learn how to buy healthy foods on a budget.
• Health Coaching: One-on-one health coaching for members to achieve healthrelated goals, like quitting smoking and weight loss.
Service Area
• No Statewide coverage limited to 3 counties & 1 rating area
95
Denver Health Medical Plan / ELEVATE
Service Area
DH
96
DH
DH
96
Humana
Individual Market
Company at a glance
• Works with you to put you in control of your healthcare costs.
• Offers access to valuable tools to give you greater control of your
healthcare dollar.
• Gives you access to health and well-being tools that remind you to
live well.
Service Area
• No Statewide coverage limited to 8 counties & 2 rating areas
97
97
Humana Service Area
Humana
Humana
Humana
Humana
Humana
Humana
98
Humana
98
Kaiser Permanente
Individual & Small Group Market
Thrive is the philosophy we live by. It’s the belief that being healthy is the basis for
living well and embracing all the possible ways you can flourish and prosper. To
help you reach your highest state of well-being we offer convenience, patientcentered care, online accessibility, tips and tools for wellness, and more.
• CONVENIENCE — At most Kaiser Permanente facilities and medical centers, you
get one-stop service for primary care, lab tests, X-rays, and pharmacy.
• CHOICE — Make an informed choice by reviewing our doctors’ credentials
online — education, certifications, secondary languages, and specialties. And
you have the option of changing your primary care physician any time.
• INNOVATIVE TOOLS — Stay connected to your health 24/7 with your electronic
health record. You can refill most prescriptions, schedule routine appointments,
email your doctors, view most lab results, and much more — all from the
convenience of your computer or phone.
Service Area:
• No Statewide coverage limited to 24 counties & 8 rating areas
99
99
Kaiser Permanente Service Area
KPDB
KPDB
KPNC
KPDB
KPDB
KPDB
KPDB
KPDBKPDB
KPDB
KPDB
KPDB
KPDB
KPDB
KPDB
KPCS
KPCS
KPCS
KPCS
KPCS
KPCS
KPCS
KPCS
KPCS
100
100
Rocky Mountain Health Plans
Individual & Small Group Market
Rocky Mountain Health Plans believes preventive care and a healthy lifestyle are key
to maintaining good health. We offer a variety of health and wellness programs
which give our Members the tools to stay in control of their health.
Rocky Mountain Health Plans’ worksite wellness programs provide the tools and
resources to assist employers in improving the health of their employees.
Rocky Mountain Health Plans offers Disease Management Programs that help our
Members manage chronic health conditions. Our programs offer learning materials,
advice and care tips.
Rocky Mountain Health Plans’ Foundation funds projects that:
• Help pregnant women to stop smoking by providing free diapers as an incentive
to quit.
• Support weight management programs for kids and their parents.
• Promote physical activities for students during the school day.
• Help homeless students maintain good hygiene by providing hygiene kits.
Service Area – Statewide coverage both PPO & HMO
101
101
SeeChange Health Insurance
Small Group Market
SeeChange Health focuses on wellness and prevention, which is why we pay you to
see your doctor. Employees (and spouses/domestic partners) earn rewards for
completing easy, voluntary preventive Health Actions:
• a short, online Health Questionnaire
• a Biometric Screening (basic lab tests)
• a Preventive Exam including cancer screenings.
It’s that easy. And we pay 100% of the cost of for completing your preventive Health
Actions. It pays to be proactive. Members receive financial rewards each year for
completing their preventive Health Actions. Rewards vary based on the plan
selected, including:
• Deposits into a Health Incentive Account (HIA)
• Deductible reimbursement
When preventive Health Actions uncover specific chronic conditions members can
earn more rewards for completing additional Health Actions aimed at helping them
manage those conditions.
102
102
Service Area – Statewide coverage
UnitedHealthcare / All Savers
Individual Market
Unique Offerings and Programs :
• At Home and on the Go: We are here when you need us and where you need us.
You can reach us on the phone (Customer Service line), online (myuhc.com) or
your cell phone (Health4Me app).
• Source4Women is an online resource on myuhc.com where women can find
information and tools for health, fitness, nutrition and more. The website offers a
community where women can learn from one another, share stories and attend
free webinars on many women’s health issues.
• UHC.TVSM is the first-ever online TV channel dedicated to making health care
more human. This public website explains health care benefits in everyday
language and features humorous and heart-warming videos
• Premium Designation: The UnitedHealth Premium® designation program is a
simple two-star rating system to help you see which doctors and specialty centers
in your area are recognized for providing quality and cost-efficient care.
Service Area:
• No Statewide coverage limited to 47 counties & 5 rating areas (Not in Denver)
103
103
United HealthCare / All Savers Individual
Service Area
UHC
UHC
UHC
UHC
UHC
UHC
UHC
UHC
UHC
UHC
UHC
UHC
UHC
UHC
UHC
UHC
UHC
UHC
UHC
UHC
UHC
UHC
UHC
UHC
UHC
UHC
104
UHC
UHC
UHC
UHC
UHC
UHC
UHC
UHC
UHC
UHC
UHC
UHC
UHC
UHC
UHC
UHC
UHC
UHC
UHC
UHC
104