Bronze, Silver and Coinsurance/Copay

[audreyh1]

I have been following and reading a bunch on this site (thanks to everyone for contributing!) but many things are not clear.

I thought that Bronze plans meant 40% or 30% coinsurance for the customer (up to the max out of pocket, I assume), an

But on the BCBS TX site, I only see options for 80% coinsurance (20% from customer) for both the Bronze and Silver plans. The differences seem to be the deductible, with the Bronze plans pretty much having deductible=max out of pocket with no full pay for doctors visits, and the Silver having half the deductible, low fixed copays for doctors visits, and 80% coinsurance (customer pays 20% I assume) up to the max out-of-pocket.

The difference between the Bronze and Silver is essentially $1200 a year, so if you think you'll spend less on your doctors visits, if would be best to just pay the doctor as needed, I would think.

Just wondering why this 40/30/20% I read about doesn't seem to show up on the TX options even though Bronze and Silver are spelled out?

 

[brewer12345]

The 40/30/20 is not teh same as coinsurance rates. Instead, the standard is that Bronze is supposed to cover 60% of your actuarially estimated total healthcare costs, Silver 70% and Gold 80%. The calculation to get to those numbers is complicated and opaque if you are not a health actuary.

 

[ziggy29]

I have been following and reading a bunch on this site (thanks to everyone for contributing!) but many things are not clear.

I thought that Bronze plans meant 40% or 30% coinsurance for the customer (up to the max out of pocket, I assume), an

But on the BCBS TX site, I only see options for 80% coinsurance (20% from customer) for both the Bronze and Silver plans. The differences seem to be the deductible, with the Bronze plans pretty much having deductible=max out of pocket with no full pay for doctors visits, and the Silver having half the deductible, low fixed copays for doctors visits, and 80% coinsurance (customer pays 20% I assume) up to the max out-of-pocket.

The difference between the Bronze and Silver is essentially $1200 a year, so if you think you'll spend less on your doctors visits, if would be best to just pay the doctor as needed, I would think.

Just wondering why this 40/30/20% I read about doesn't seem to show up on the TX options even though Bronze and Silver are spelled out?

My understanding is that Bronze simply means that the plan pays out 60% of expected expenses in insurance benefits. That can be achieved with lower copayments and higher deductibles and OOP limits as well as with higher copays.

Also in some cases, the deductible and OOP limits can be further reduced in the Silver plans (but not the Bronze) with sufficiently low MAGI since cost sharing can kick in.

 

[audreyh1]

The 40/30/20 is not teh same as coinsurance rates. Instead, the standard is that Bronze is supposed to cover 60% of your actuarially estimated total healthcare costs, Silver 70% and Gold 80%. The calculation to get to those numbers is complicated and opaque if you are not a health actuary.

Great, Thanks - and to Ziggy too. I never quite got that.

Yeah - I guess that is meaningless to me as a consumer.

I just think in terms of X amount per year for doctors visits, copays, etc. that are not covered - I either pay the insurance company, or I pay the clinic/doctor directly. So $100 a month goes to one or the other.

$1200 would cover a lot of doctor's visits (basic screening is already included in the policy, so mammogram, physical, basic blood work, etc. is already paid for by the policy). So in general, that $1200 would be for "extra" stuff, and still applies towards the deductible.

The max-out-of-pocket per year is the main issue for us.

No cost-sharing or subsidies for us. I hope that makes signing up easier.

 

[ziggy29]

No cost-sharing or subsidies for us. I hope that makes signing up easier.

It should, since it means you don't need to go through the (broken) Exchange web site -- you can purchase directly through the insurer, and you should get the same price. You may also have more coverage options outside the Exchange, too.

 

[audreyh1]

I'm currently on a BCBS TX PPO, so that's what I want to continue.

For me the main issue is which flavor of Bronze or Silver do I chose, and right now I'm leaning toward the Bronze where deductible=max-out-of-pocket of $6000. The other Bronze option has the deductible at $5000, max-out-of-pocket of $6250, and 80% coinsurance after deductible. The difference is $3 a month.

It's one of those splitting hair differences that you can spend an awful lot of time on!

The silver plans are $100 more a month.

Yep - I'm really hoping I can sign up directly and not have to use healthcare.gov.

I haven't tried yet, because I haven't made the final decision on the plan.

 

[audreyh1]

I did check directly with BCBS and through healthcare.gov and saw the same plans, same plan codes, etc. listed. The prices didn't jive, but I think that's because healthcare.gov wasn't using my exact birth date.

 

[ziggy29]

I'm currently on a BCBS TX PPO, so that's what I want to continue.

For me the main issue is which flavor of Bronze or Silver do I chose, and right now I'm leaning toward the Bronze where deductible=max-out-of-pocket of $6000. The other Bronze option has the deductible at $5000, max-out-of-pocket of $6250, and 80% coinsurance after deductible. The difference is $3 a month.

It's one of those splitting hair differences that you can spend an awful lot of time on!

Yeah. It looks like there are three bands here:

* Under $5000 in costs: better to take the $6000 deductible since it's $36 less per year.

* Over $10000 in costs: Better to take the $6000 deductible since the other plan will result in OOP costs over $6000.

* Between $5000 and $10000: This appears to be where the $5000 deductible plan is a little better.

But the reality is that the "wrong" choice will never cost you more than $286 so it may not be worth agonizing over.

 

[Texas Proud]

One of the things that I found out this past year is that the deductible and max OOP expenses are not the same...

IOW, I have a $5K deductible with $6K max OOP... when I passed the deductible I thought I only had $1K more OOP... wrong... I now have $6K more that I can pay...


With this, I want to make sure that I am not taking on more risk than I want....

 

[audreyh1]

That is on your current plan, but on the new ACA compliant plans, the deductible and coinsurance payments apply towards your annual max out-of-pocket. I think that's pretty clear from the literature.

That used to be a huge disparity between plans that made them difficult to compare.

 

[clifp]

I'm currently on a BCBS TX PPO, so that's what I want to continue.

For me the main issue is which flavor of Bronze or Silver do I chose, and right now I'm leaning toward the Bronze where deductible=max-out-of-pocket of $6000. The other Bronze option has the deductible at $5000, max-out-of-pocket of $6250, and 80% coinsurance after deductible. The difference is $3 a month.

It's one of those splitting hair differences that you can spend an awful lot of time on!

The silver plans are $100 more a month.

Yep - I'm really hoping I can sign up directly and not have to use healthcare.gov.

I haven't tried yet, because I haven't made the final decision on the plan.

In theory my existing Kaiser plan is grandfather in, but I have no idea what the price will be. If I do get an exchange plan my initial thought I would get a silver plan, but the more I looked at looked like in many cases bronze would actually cheaper. The price difference in Hawaii between bronze and silver is $100/month. Bronze Co-Insurance is 40%, silver 30%

For the normal years, when I go to the doctor once a year for my physical. Bronze saves me $1200/year.
If I get really sick like cancer, under bronze or silver I'll max out the 6350 out of pocket expenses. However, my understanding that number doesn't include premiums. So once again bronze saves me money.
It seems that it is only a relatively narrow range of accidents/illness costing about ~$10,000 where the lower deductible of the silver plan saves me more money than additional premiums got and even then the max saving is only a few thousand.

I would think if the co insurance is 20% in Texas that normally the bronze would be a better deal.

 

[MichaelB]

I'm doing mostly the same as you, went directly to the BCBS Fl site and did all my research. I still need to look at Humana and Aetna, but our BCBS choice is in place and looks likely.

What surprises me is the pricing you imply. There is substantial difference among the BCBS Fl plans (same network), easily a couple of $K in total cost after taking into consideration premiums, deductibles, TOOP, etc. The advantage is clearly to the HSA, and then to the highest deductible, even before considering the value of the tax effect. I'm going to look at my spreadsheet again, just to make sure I haven't messed up somewhere.

That is on your current plan, but on the new ACA compliant plans, the deductible and coinsurance payments apply towards your annual max out-of-pocket. I think that's pretty clear from the literature.

That used to be a huge disparity between plans that made them difficult to compare.

 

[Texas Proud]

That is on your current plan, but on the new ACA compliant plans, the deductible and coinsurance payments apply towards your annual max out-of-pocket. I think that's pretty clear from the literature.

That used to be a huge disparity between plans that made them difficult to compare.

I need to learn more about this....

So what you are saying is that no matter what plan you buy the max you spend is the $6K something per person per year That includes all copays, tests, other bills etc.?

 

[audreyh1]

I'm doing mostly the same as you, went directly to the BCBS Fl site and did all my research. I still need to look at Humana and Aetna, but our BCBS choice is in place and looks likely.

What surprises me is the pricing you imply. There is substantial difference among the BCBS Fl plans (same network), easily a couple of $K in total cost after taking into consideration premiums, deductibles, TOOP, etc. The advantage is clearly to the HSA, and then to the highest deductible, even before considering the value of the tax effect. I'm going to look at my spreadsheet again, just to make sure I haven't messed up somewhere.

Well, I'm reviewing this all very carefully as you can imagine.

Yes - substantial differences in premiums, but depending on the plan, the insurance might be paying a lot more for your care before you meet the deductible yourself.

 

[audreyh1]

I need to learn more about this....

So what you are saying is that no matter what plan you buy the max you spend is the $6K something per person per year That includes all copays, tests, other bills etc.?

There is an ACA annual max out-of-pocket limit of $6350 for the individual. Some plans offer a lower limit than that - but the ones I have seen just offer some slightly lower options. All in all, if you pay for more coverage and need a lot of care, you'll take longer to hit that personal max. If you pay for less coverage, you could hit that max quite quickly if you suddenly needed a lot of care, but with little care needed, you might still spend less than the premium difference.

I'm not sure whether co-pays are included (the $30 to visit doctor, etc.), but as far as I can determine, the deductible and coinsurance payments are.

This max also does not include OUT-OF-NETWORK charges which could easily increase your annual max out-of-pocket expenses. The insurance company is only obligated to pay an out-of-network provider what they have negotiated with their in-network providers, and the provider can then bill you for the balance. This looks like an achilles heel. Out of network charges can often be avoided, but not always.

 

[audreyh1]

In theory my existing Kaiser plan is grandfather in, but I have no idea what the price will be. If I do get an exchange plan my initial thought I would get a silver plan, but the more I looked at looked like in many cases bronze would actually cheaper. The price difference in Hawaii between bronze and silver is $100/month. Bronze Co-Insurance is 40%, silver 30%

For the normal years, when I go to the doctor once a year for my physical. Bronze saves me $1200/year.
If I get really sick like cancer, under bronze or silver I'll max out the 6350 out of pocket expenses. However, my understanding that number doesn't include premiums. So once again bronze saves me money.
It seems that it is only a relatively narrow range of accidents/illness costing about ~$10,000 where the lower deductible of the silver plan saves me more money than additional premiums got and even then the max saving is only a few thousand.

I would think if the co insurance is 20% in Texas that normally the bronze would be a better deal.

Yeah - that is what I seeing between Bronze and Silver. I can budget up to $1200 for doctor visits beyond the basics already paid for: physical, mammogram, basic blood tests. And pay the bronze premiums. With the silver I might have benefits like doctor copays limited to $30 or $35 and a few other things, but I'm also paying an extra $100 a month.

The options I'm seeing on Bronze are:

Deductible and Max-out-of-pocket are both the same - around $6K. So basically you would pay up to your deductible and insurance would cover 100% of everything above that as long as it was in-network.
This scenario: Total Medical Bills = $6000 or more - you pay $6000.

Deductible is $5000, Max-out-of-pocket is $6250. So you pay up to your deductible, then you pay 20% until you reach $6250. In this scenario, the insurance company would be paying out $5000 before you reach your $6250 max out-of-pocket limit. And then they pay 100%.
This scenario: Total Medical Bills = $11,250 or more - you pay $6250. You might get to $5000 quickly, but then it slows down.

The monthly premium difference between the two is around $3, essentially a wash.

Yep - deductibles never include premiums.

 

[ERhoosier]

I need to learn more about this....

So what you are saying is that no matter what plan you buy the max you spend is the $6K something per person per year That includes all copays, tests, other bills etc.?

That $6k/yr max is "OOP max", but does not include HI premiums nor test/treatments not covered. Those can add up. Also- Check out-of-network coverage very carefully. Most Exchange Plans in my area have OON coverage, so individual would be responsible for all OON costs

 

[tinlizzy]

I believe that prescription coverage that is outsourced within a plan can also charge the max oop or have no limits, in addition to the major medical oop. Prescription coverage offered by the major medical provider will be included in the max oop.

I'm sorry I didn't bookmark half the things I've read because they don't apply to me yet and I figure they'll probably change....

 

[sengsational]

It would be cool to have a simulator that was sort of like firecalc....one that tries a bunch of scenarios. You'd put in the plans and costs of those plans and what kinds of HC services you expect beyond the 100% covered preventive stuff. So a 95% chance each family member goes to the doctor 1 time a year (typical in my family's case), a 3% chance of an illness/accident that costs $10,000 and spans X months, etc. Your best time to have something really bad / expensive happen to you is during open enrollment...then you'd just go for platinum! The simulator would have to be smart enough to bump you up to the higher coverage plan if, during one of its simulation runs, you got a long, expensive illness. Yeah, so this all implies it the simulator would model multiple years.

I have a feeling I know what the 'answer' would be for the healthy family...get the least expensive thing on the menu, and switch to the most expensive when you know you're going to need it, if that sad day ever comes.

 

[MichaelB]

I believe that prescription coverage that is outsourced within a plan can also charge the max oop or have no limits, in addition to the major medical oop. Prescription coverage offered by the major medical provider will be included in the max oop.

I'm sorry I didn't bookmark half the things I've read because they don't apply to me yet and I figure they'll probably change....

Is this it? Federal Rule Allows Higher Out-Of-Pocket Spending For One Year - Kaiser Health News

According to guidance from the federal government issued in February, health plans with more than one benefits administrator don't have to combine their tallies of members’ out of pocket spending into one total until 2015. So a plan with a separate cap on pharmacy benefits can keep it as long as the limits don't exceed the new maximum. Plans with no drug spending limit—the norm, according to experts—don't have to cap members' out-of-pocket spending at all.

 

[audreyh1]

Right now it looks like the Silver plans are the "co-pay" plans with prices set out for Doctor's visits, prescription drugs, various outpatient things, emergency room visits, etc. So when you go for something, it's not a huge amount out of pocket, but you pay higher premiums for that "privilege".

The Bronze plans have no copays, you pay for everything (beyond the basic annual preventative stuff), including prescription drugs, up to the deductible, but you pay lower premiums.

Of course you get the negotiated plan rates in both cases which are the most important thing.

 

[GLM]

Ok going to ask a basic question this general conversation has me wondering about. When a plan has a co-pay for a doctor visit of say $35, what does that mean? Say I get a bad lung infection and end up seeing my GP. ( I've only done the annual physical thing for ? years - I think I did go for a lower respiratory thing about 18 years ago ) If I have not yet met my deductible do I pay the full negotiated rate or just $35?

I always thought the co-pay only applied after the deductible .

I believe in letting my immune system fighting for me , and it has consistently risen to the task when called upon. Also, I am convinced my regular exercise sort of pasteurizes germs out of my system.

 

[tinlizzy]

Is this it? Federal Rule Allows Higher Out-Of-Pocket Spending For One Year - Kaiser Health News

Yes but it was an article that linked to that. The article was about a couple whose present day insurance plan had no limits on prescription oop and he was dx'ed with cancer and the meds destroyed them financially.

 

[Texas Proud]

Ok going to ask a basic question this general conversation has me wondering about. When a plan has a co-pay for a doctor visit of say $35, what does that mean? Say I get a bad lung infection and end up seeing my GP. ( I've only done the annual physical thing for ? years - I think I did go for a lower respiratory thing about 18 years ago ) If I have not yet met my deductible do I pay the full negotiated rate or just $35?

I always thought the co-pay only applied after the deductible .

I believe in letting my immune system fighting for me , and it has consistently risen to the task when called upon. Also, I am convinced my regular exercise sort of pasteurizes germs out of my system.

The copay in my policy (not saying all as I am sure there might be an exception) is how much I pay to see a doctor.... my copay is $50 for GP and $75 for specialist... So, if I go to the doc the first day of the policy year, I pay $50 and insurance pays the rest... this amount does not count toward my deductible...


My DW recently had knee surgery and we had to pay $75 for each physical therapy session.... even after we met the full deductible.... so they keep coming no matter what....

 

[donheff]

Ok going to ask a basic question this general conversation has me wondering about. When a plan has a co-pay for a doctor visit of say $35, what does that mean? Say I get a bad lung infection and end up seeing my GP. ( I've only done the annual physical thing for ? years - I think I did go for a lower respiratory thing about 18 years ago ) If I have not yet met my deductible do I pay the full negotiated rate or just $35?

I always thought the co-pay only applied after the deductible .

I believe in letting my immune system fighting for me , and it has consistently risen to the task when called upon. Also, I am convinced my regular exercise sort of pasteurizes germs out of my system.

The copay in my policy (not saying all as I am sure there might be an exception) is how much I pay to see a doctor.... my copay is $50 for GP and $75 for specialist... So, if I go to the doc the first day of the policy year, I pay $50 and insurance pays the rest... this amount does not count toward my deductible...


My DW recently had knee surgery and we had to pay $75 for each physical therapy session.... even after we met the full deductible.... so they keep coming no matter what....

I too am a little unclear on this. From the discussion above I got the impression that on some (most?) plans you pay the full amount of the negotiated rate until you reach your deductible and then pay only copays. But it sounds like on others you pay a portion of costs until you have paid out the deductible and then switch over to copays. Is that correct? And how do you all get the plan details? Do you have to go to the insurers site? When I looked at health.gov results I saw only the brief plan summary, no details and no link for details.