Time to switch? Consumers with low-cost Covered California plans can expect to pay full cost for ER visits, hospitalization

People who pay as little as $1 a month for the lowest-cost health plans through Covered California should be aware of a benefit change for 2016, health advocates said.

Starting Jan. 1, bronze plans won’t cover emergency room visits or hospitalization until the customer reaches the out-of-pocket maximum, which will grow to $6,000 for individuals and $12,000 for families. Patients seeking hospital treatment for a broken arm or inflamed appendix will be responsible for full costs unless they have hit the maximum.

In a pricing region that includes Stanislaus, San Joaquin, Merced, Mariposa and Tulare counties, about 20 percent of the 68,000 people enrolled in Covered California policies have bronze health plans.

“Almost every person I know who chose bronze has regretted it,” said Sean Crisp of Crisp & Associates Insurance Agency in Modesto.

The certified broker said he has told customers that Covered California’s silver coverage is a better value, but still they chose bronze for the small premium. “What hurts is when they come back and say ‘I need to change – this plan is horrible,’ ” Crisp said.

Bronze plans, with a general coverage level of 60 percent of medical costs, are now regarded as the catastrophic health insurance on the Covered California menu. Different insurers offer bronze, silver, gold and platinum plans on the state-run marketplace established by federal health reform, with coverage levels ranging from 60 percent to 90 percent.

Anthony Wright, executive director of Health Access California and a leading proponent of health reform, said the bronze plans are suited for people who can insure themselves against the first $6,000 in annual medical costs and want to avoid bankruptcy if they need treatment for a major illness.

It may be the only option that some low-wage earners can afford. Consumers can change their coverage when an enrollment period for 2016 begins in November.

“If they can swing it, it makes sense to go for a silver plan because the bronze does not provide a lot of protection,” Wright said.

Crisp said bronze policyholders could be saddled with medical debt because hospitals are less willing to negotiate unpaid balances with patients.

Plans with low premiums usually have higher out-of-pocket costs for policyholders. Under bronze coverage, the patient copays in 2016 are $70 for a primary care visit, $120 for urgent care, and full cost for X-rays and hospital physician fees. The pharmacy deductible is $500.

Next year, the bronze benefits will include three primary care, mental health, urgent care or specialty care visits not subject to the deductible.

The standard coverage level for silver plans is 70 percent, but larger households and adults with lower incomes may qualify for enhanced benefits covering 80 percent or even 97 percent of costs.

According to Covered California’s online “Shop and Compare” tool, a 40-year-old earning $17,000 a year could upgrade from an Anthem Blue Cross bronze policy, costing $1 per month, to an Anthem silver plan with 94 percent coverage, costing $39 a month. The deductibles are $75 for medical and zero for drugs.

The silver copays are $5 for primary care, $6 for urgent care, $30 for emergency room and $8 for lab tests. The enhanced plan covers 90 percent of hospitalization costs and has a maximum out-of-pocket limit of $2,250.

Laura Hunt of Modesto said she has an Anthem silver plan that costs $19 a month this year. The home health worker should be able to manage a 10 percent premium increase next year.

She said she worked with a counselor at the exchange to get the best package. “My deductible is zero. I paid $20 last year for minor surgery in the doctor’s office and got my hearing back,” said Hunt, who sees a doctor at Greater Modesto Medical Surgical Associates.

A family of four with annual earnings of $40,000 could upgrade their $2-a-month bronze Kaiser Permanente plan to Kaiser silver enhanced for $157 monthly or Anthem silver enhanced for $129 monthly. The silver plan deductibles are $1,100 for medical and $100 for drugs; the maximum out-of-pocket is $4,500.

In the Northern San Joaquin Valley, the four insurers that offer plans – Anthem, Blue Shield, Kaiser and Health Net – propose to raise premiums by an average of 10 percent next year. That’s more than twice the average premium increase for Covered California plans.

Officials with Covered California said residents can soften the impact by choosing a lower-cost plan in the same coverage tier.

Crisp countered that he doesn’t advise customers to change insurers just to save a few dollars. More than 90 percent of consumers in the region receive financial help to lower their premiums. Among those with subsidies, the average premium for silver plans will increase from $105 a month to $118 a month.

Crisp noted that Anthem Blue Cross usually has the cheapest rates. But his customers holding those policies have the hardest time getting access to doctors, he said. “They may tell you they take it but then you can’t get in for an appointment for six months,” Crisp said.

Anyone planning to switch to more affordable insurance should ask their doctors if they accept it, Crisp said. It could involve changing to a different health care model, such as Kaiser’s managed-care system, and consumers should consider whether that is acceptable.

In another change in 2016, Covered California will put a $250-a-month cap on high-cost drugs that treat Hepatitis C, HIV, multiple sclerosis and other diseases.

Consumers can review their options for 2016 coverage by using Covered California’s “Shop and Compare” tool at www.coveredca.com.

This story was originally published August 20, 2015 at 10:52 AM with the headline "Time to switch? Consumers with low-cost Covered California plans can expect to pay full cost for ER visits, hospitalization."