We have not seen California health coverage this rich since...well it's been over a decade. The California Exchange has released their basic blue print for the four different Metallic health plans in California and at the top of the list is the new Platinum plan. Let's take a look at the core benefits and who it might make sense for. We'll also look at what we expect in terms of pricing which will be critical.
You can find detail here on the core plan benefits but we'll hit the highlights below. Keep in mind that this is the baseline plan provided by the Exchange. Carriers can have slightly different versions of it and benefits by 4% but the overall coverage needs to stay close to the 90% actuarial value reflected in their baseline plan.
This is really the big deal with the Platinum core benefits. There will likely be no deductible for core benefits or for medication. We really haven't had a no-deductible health plans (non-HMO) for years now due to cost and the effects of years of rate increases.
The next big important benefit is the Max out of pocket which sums up when you can expect covered benefits (in-network) to go 100% to the carrier. The OOP (Out of Pocket Max) is listed at $4K which is better than almost any plan on the current market. The coinsurance (percentage that you will pay to meet the max) is 10% which makes the Platinum California Exchange plan a 90/10 plan. This is also very rich compared to the current market.
The plan lists a $25 primary physician visit copays and $50 for specialists. There are no limits on the number of visits a person can have. The RX copays are $5 generic, $15 brand formulary, and $25 brand non-formulary. Again, there is no deductible for brand RX which has been the norm on the market with some of the most popular plans having very large deductibles. Preventative benefits will be covered at 100%.
This is the section that has seen the most change over the past 5 years on the California health market with the popularity and cost of MRI's, Cat-scans, x-rays, and the like. Labs will be covered with a $25 copay, x-rays will have a $40 copay, and imaging (MRI's, CAT scans, etc) will be subject to the 10% coinsurance (you pay 10%). This is extremely rich which brings us to the most important part of our analysis...what will the cost be for the California Platinum Health Plan?
If the past 10 years is any indication, the Platinum California plan will not have many takers with one exception...the very sick. Keep in mind that the subsidies available in California are only for the Bronze plan (in-Exchange). No subsidies will be available for the Platinum plan. The rich benefits are great but no one will likely pay the significantly higher premium that is required. The only people that might are those with very large medical costs. This attraction of higher risk is the generally very bad for any kind of insurance and it even has it's own technical name (adverse selection). Our estimate is that the Platinum health plan will likely make up 3-5% of the new enrollment at best and we see this dropping with time as a higher risk pool drives the premiums through the roof in year two or three. Very quickly the annual premium difference will more than offset the best possible benefit difference and the movement downward in benefits will accelerate.
Either way, you will be able to quote all the Metallic health plans including the Platinum, Gold, Silver, Bronze and Catastrophic (adults under 30) plans with or without health subsidies starting October 1st here.
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