health plan market & benefit comparison part ii presented by cliff craig health plan account...
TRANSCRIPT
Health Plan Market &
Benefit Comparison Part II Presented by Cliff CraigHealth Plan Account Manager for Connect for Health Colorado
22
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 Offeringo Health Shop / Small Groupo Health Individualo Dental Shop / Small Groupo Dental Individual
• Carriers Benefit Comparison by Metal Tiers
• Carrier Specific Key Points & Service Area
33
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)
4
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
55
What Applies to Maximum Out-of-Pocket HMO & EPO Plans
Copayments Deductibles
Coinsurance
Maximum Out-of-Pocket
$6,350 / $12,700
Rx Deductibles
RxCopayments
RxCoinsurance
Prevention
66
Embedded VS Aggregate Family Deductibles & Out-of-Pocket Maximums
There are two different types of deductibles: traditional, also called Embedded(Per-Member), 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.
77
Embedded / Per-Member Family Deductible & Out-of-Pocket Maximum
Father$2000
Mother$3000
Child$500
$3000 Individual $6000 Family Deductible
FatherMother$6350 Child
Coinsurance
$6350 Individual $12700 Family OOP Max.
Prevention
Each family member must meet the
Individual Deductible before coinsurance
applies for them only
88
Embedded / Per-Member Family Deductible & Out-of-Pocket Maximum
Father$3000
Mother$3000 Child
$3000 Individual $6000 Family Deductible
Father$6350
Mother$6350 Child
Coinsurance
$6350 Individual $12700 Family OOP Max.
Prevention
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
99
Embedded / Per-Member Family Deductible & Out-of-Pocket Maximum
Father$2000
Mother$3000
Child$500
$3000 Individual $6000 Family Deductible
FatherMother$6350 Child
Coinsurance
$6350 Individual $12700 Family OOP Max.
Prevention
The mother was theonly family member accessing care. Shemet her Individual Deductible& Out-of-Pocket max so she isthe only family member coveredat 100%
1010
Aggregate / Single Family Deductible & Out-of-Pocket Maximum
Father$2000
Mother$3500
Child$500
$3000 Individual $6000 Family Deductible
Prevention
The family as a group can meet the Family
Deductible
Coinsurance for allFamily members
1111
Aggregate / Single Family Deductible & Out-of-Pocket Maximum
$3000 Individual $6000 Family Deductible
Father$6000
Mother$5000
Child$1700
$6350 Individual $12700 Family OOP Max.
Prevention
The family as a group has met the Family Out-Of-Pocket Max.
Coinsurance for allFamily members
1212
Aggregate / Single Family Deductible & Out-of-Pocket Maximum
Father$2000
Mother$3500
Child$500
$3000 Individual $6000 Family Deductible
Father$6000
Mother$5000
Child$1700
Coinsurance
$6350 Individual $12700 Family OOP Max.
Prevention
The family as a group met the Family
Deductible & the Family Out-of-Pocket Max.
1313
Aggregate / Single Family Deductible & Out-of-Pocket Maximum
FatherMother$6000 Child
$3000 Individual $6000 Family Deductible
FatherMother$12700 Child
Coinsurance
$6350 Individual $12700 Family OOP Max.
Prevention
The mother was theonly family member accessing care. Shemet the Family Deductible& Out-of-Pocket max for theentire family
1414
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.) Non-Preferred & 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.
Sample of How Benefits Accumulate for a Family of Three Policy
Dads Medical Services Cost of servicesFamily
expensesApplies to Med Ded
Applies to Rx Ded
Applies to OOP max
RMHP expenses
Prevention visit $100 $0 $0 $0 $0 $100PCP visit $100 $40 $0 $0 $40 $60PCP orders meds Preferred $140 $140 $0 $140 $140 $0Inpatient Hospital (2nd) $5,000 $3,600 $3,000 $3,600 $1,400
(Dad paid $3000 & $600 (30% of $2000) Family Ded met X-rays & Lab $1,000 $300 done $0 $300 $700Physician surgery $1,000 $300 done $0 $300 $700
InptHospmeds 1 Pref / 1 Spec $400 $400 $0 $400 $400 $0Emergency visit (4th) $2,000 $600 done $0 $600 $1,400
Dads Total $9,740 $5,380 $3,000 $540 $5,380 $4,360Moms Medical Services Prevention visit $150 $0 $0 $0 $0 $150OB/GYN Visit $200 $40 $0 $0 $40 $160PCP visit $100 $40 $0 $0 $40 $60OutPatient Surgery (3rd) $2,000 $600 done $0 $600 $1,400Lab $500 $150 done $0 $150 $350Outpt meds Preferred $110 $110 $0 $110 $110 $0Outpt meds Preferred $200 $60 $0 done $60 $140Outpt meds Generic $75 $15 $0 done $15 $60
Moms Total $3,335 $1,015 $0 $110 $1,015 $2,320Baby Bears Medical Services Prevention visit $80 $0 $0 $0 $0 $80Emergency visit (1st) $1,000 $250 $0 $0 $250 $750Ambulance ride to ER $1,000 $1,000 $1,000 $0 $1,000 $0ER test MRI $1,000 $1,000 $1,000 $0 $1,000 $0ER meds Specialty Drug $200 $200 $0 $200 $200 $0ER med Preferred $150 $150 $0 $150 $150 $0ER med Generic $75 $15 $0 $0 $15 $60
Baby Bears Total $3,505 $2,615 $2,000 $350 $2,615 $890Family Total $16,580 $9,010 $5,000 $1,000 $9,010 $7,570
15
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
1616
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 non-
medical expenses, before the age 65.
1717
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
HSA contribution limit (employer + employee)
Individual:$3,300Family:$6,550
Individual:$3,250
Family:$6,450
Individual:+$50
Family:+100
HSA catch-up contributions (age 55 or older)*
$1,000 $1,000 No change**
HDHP minimum deductibles Individual:$1,250Family:$2,500
Individual:$1,250
Family:$2,500
No change
HDHP maximum out-of-pocket amounts (deductibles, co-payments and other amounts, but not premiums)
Individual:$6,350Family:$12,700
Individual:$6,250
Family:$12,500
Individual:+$100
Family:+$200
* 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.
1818
HSA Penalties & Children Coverage
Penalties for Nonqualified ExpensesThose 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 ChildrenWhile 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.
1919
Health Savings Account (HSA) / High Deductible Health Plans (HDHP) Eligible Plans
Access Health
CO
Anthem
Cigna
CO C
hoice H
ealth
Colora
do Health
OP
Denver Health
Med
Humana
Kaiser P
ermanente
Rocky MHP
SeeChange
UnitedHealth
care
0
2 2 2
0 0
2
9 9
0
2
0 0 0
23
0 0
9
11
2
0
Individual Small Group
2020
What Applies to Maximum Out-of-Pocket HSA & HDHP Plans
Copayments
Deductibles
Coinsurance
Maximum Out-of-Pocket
$6,350 / $12,700
RxCopayments
Prevention
2121
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
Premium $158.37 $164.97 $208.52
% increase Lowest Plan 4% 24%
2222
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 $258.06 $323.61
% increase Lowest Plan 12% 30%
23
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
2424
Plan Documents Can Help Make Final Decision
Evidence of Coverage, Policy, Summary of Benefits: It’s the membersContract with the carrier(about 80 plus pages) varies by carrierEnglish only Summary of Benefits and Coverage, is a summary
of benefits (not a binding contract), standard benefitLayout (9 pages) English & Spanish
Company Profile: Standard documentCovers – Company at a glance, MedicalLoss Ratio, Unique Offerings & Programs,Awards & Recognition,& In the Community.English & Spanish
Quality Overview: Standard Document Covers – Accreditations, Consumer Complaints, How the planmakes members healthier / works with providers /examples of innovative approaches, Quality Ratings.English & SpanishCarrier Marketing materials:
Not Standard, Varies by carrierEnglish & Spanish
2525
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 andthe PPO plan is not illustrating the Out of Network Tier benefit information
2626
The compare function is utilizedbest when comparing two differentcarriers or plans that are close inpremium and now its which oneprovides the best benefit for the
COST
Key Things to Know When Using Plan Compare Function
2727
Key Things to Know When Using Plan Compare Excel File
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 $30 $30 Coinsurance No Charge No Charge
Other Practitioner Office Visit (Nurse, Physician Assistant) Copay $60 $60 Coinsurance No Charge No Charge
Preventive Care/Screening/Immunization Copay $0 $0 Coinsurance No Charge No Charge Specialist Visit Copay $60 $60 Coinsurance No Charge No Charge Nutritional Counseling Copay No Charge No Charge Coinsurance 35% Coinsurance after deductible 35% Coinsurance after deductible
This is a snapshot of 2 Colorado HealthOP Bighorn EPO ($276.42) & PPO ($315.78)
Issue with the Plan Compare is neither product has an In Network Tier Two benefit listed andthe PPO plan is not illustrating the Out of Network Tier benefit information
2828
Colorado HealthOP Bison PPO Plan Benefits Page Information
Notice the Enhance benefitinformation is not listed on thePlan Benefits Page. The In-Network Tier 2 benefit isunique to CO HealthOP only
2929
Colorado HealthOP Bison EPO Plan SBC Information
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/Copaymentscolumn 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
Services You May Need
Your Cost If You Use a
Network Provider
Your Cost If You Use a
Non-Network Provider
Limitations & Exceptions
Primary care visit to treat an injury or illness
Standard First visit free subject to the deductible. Subsequent visits are 40% coinsurance/visit.
Enhanced* First visit free. Subsequent visits $30 copayment/ visit and not subject to the deductible.
Not Covered
* 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.
Specialist visit
Standard 40% coinsurance/visit
Enhanced* $60 copayment/ visit
Not Covered
---None---
Other practitioner office visit
Standard 40% coinsurance/visit
Enhanced* 40% coinsurance/visit
Not Covered
---None---
3030
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 clarifiedas Not Covered. PPO plans willhave benefit levels listed in bothIn Network & Out of Network tiers
3131
Common Medical Event
Services You May Need
Your Cost If You Use an
Network Provider
Your Cost If You Use an
Non-network Provider
Limitations & Exceptions
If you need drugs to treat your illness or condition
More information about prescription drug coverage is available at www.humana.com.
Level 1 – Preferred Generic $10 copay (Retail) $20 copay (Mail Order)
Not Covered Preauthorization required, penalty may apply. 30 day supply (Retail) 90 day supply (Mail Order)
Level 2 – Non-preferred Generic $20 copay (Retail) $40 copay (Mail Order)
Not Covered See Level 1 for Limitations and Exceptions
Level 3 – Preferred Brand $50 copay (Retail) $100 copay (Mail Order)
Not Covered See Level 1 for Limitations and Exceptions
Level 4 – Non-preferred Brand 50% coinsurance Not Covered See Level 1 for Limitations and Exceptions
Level 5 – Specialty drugs 50% coinsurance Not Covered Preauthorization required, penalty may apply. 40% coinsurance when filled via a preferred network specialty pharmacy
If you have outpatient surgery
Facility fee (e.g., ambulatory surgery center) 20% coinsurance Not Covered Preauthorization required, penalty may apply.
Physician/ surgeon fees 20% coinsurance Not Covered -----------------none------------------------- If you need immediate medical attention
Emergency room services 20% coinsurance 20% coinsurance -----------------none------------------------- Emergency medical transportation 20% coinsurance 20% coinsurance -----------------none-------------------------
Urgent care $50 copay/visit Not Covered Cost share may vary based on where service is performed.
If you have a hospital stay
Facility fee (e.g., hospital room) 20% coinsurance Not Covered Preauthorization required, penalty may apply.
Physician/ surgeon fee 20% coinsurance Not Covered -----------------none-------------------------
Sample of an HMO SBC Regarding Emergency Room Benefits
All Emergency Services are treated as In Network benefits regardless of Facility. The Plan Page is miss leading because it shows Out of Network benefits as $0 & 100%
Urgent care is listed In Network only and at a Copay level for some plans
3232
Common Medical Event
Services You May Need
Your Cost If You Use an
Network Provider
Your Cost If You Use an
Non-network Provider
Limitations & Exceptions
If you need drugs to treat your illness or condition
More information about prescription drug coverage is available at www.humana.com.
Level 1 – Preferred Generic $10 copay (Retail) $20 copay (Mail Order)
Not Covered Preauthorization required, penalty may apply. 30 day supply (Retail) 90 day supply (Mail Order)
Level 2 – Non-preferred Generic $20 copay (Retail) $40 copay (Mail Order)
Not Covered See Level 1 for Limitations and Exceptions
Level 3 – Preferred Brand $50 copay (Retail) $100 copay (Mail Order)
Not Covered See Level 1 for Limitations and Exceptions
Level 4 – Non-preferred Brand 50% coinsurance Not Covered See Level 1 for Limitations and Exceptions
Level 5 – Specialty drugs 50% coinsurance Not Covered Preauthorization required, penalty may apply. 40% coinsurance when filled via a preferred network specialty pharmacy
If you have outpatient surgery
Facility fee (e.g., ambulatory surgery center) 20% coinsurance Not Covered Preauthorization required, penalty may apply.
Physician/ surgeon fees 20% coinsurance Not Covered -----------------none------------------------- If you need immediate medical attention
Emergency room services 20% coinsurance 20% coinsurance -----------------none------------------------- Emergency medical transportation 20% coinsurance 20% coinsurance -----------------none-------------------------
Urgent care $50 copay/visit Not Covered Cost share may vary based on where service is performed.
If you have a hospital stay
Facility fee (e.g., hospital room) 20% coinsurance Not Covered Preauthorization required, penalty may apply.
Physician/ surgeon fee 20% coinsurance Not Covered -----------------none-------------------------
Sample of an HMO SBC Regarding Unique Five Tier Rx Benefits
This plan has a five tier Rx benefit: Tier 1 Preferred Generic, Tier 2 Non-Preferred GenericTier 3 Preferred Brand, Tier 4 Non-Preferred Brand, Tier 5 Specialty Drugs. The Tier 2 Non-preferred Generic is very unique
Carriers only use one Pharmacy Network, for PPO plans when Out of Network providers writea script there is no difference in cost sharing
3333
Common Medical Event
Services You May Need
Your Cost If You Use an
Network Provider
Your Cost If You Use an
Non-network Provider
Limitations & Exceptions
If you need drugs to treat your illness or condition
More information about prescription drug coverage is available at www.humana.com.
Level 1 – Preferred Generic $10 copay (Retail) $20 copay (Mail Order)
Not Covered Preauthorization required, penalty may apply. 30 day supply (Retail) 90 day supply (Mail Order)
Level 2 – Non-preferred Generic $20 copay (Retail) $40 copay (Mail Order)
Not Covered See Level 1 for Limitations and Exceptions
Level 3 – Preferred Brand $50 copay (Retail) $100 copay (Mail Order)
Not Covered See Level 1 for Limitations and Exceptions
Level 4 – Non-preferred Brand 50% coinsurance Not Covered See Level 1 for Limitations and Exceptions
Level 5 – Specialty drugs 50% coinsurance Not Covered Preauthorization required, penalty may apply. 40% coinsurance when filled via a preferred network specialty pharmacy
If you have outpatient surgery
Facility fee (e.g., ambulatory surgery center) 20% coinsurance Not Covered Preauthorization required, penalty may apply.
Physician/ surgeon fees 20% coinsurance Not Covered -----------------none------------------------- If you need immediate medical attention
Emergency room services 20% coinsurance 20% coinsurance -----------------none------------------------- Emergency medical transportation 20% coinsurance 20% coinsurance -----------------none-------------------------
Urgent care $50 copay/visit Not Covered Cost share may vary based on where service is performed.
If you have a hospital stay
Facility fee (e.g., hospital room) 20% coinsurance Not Covered Preauthorization required, penalty may apply.
Physician/ surgeon fee 20% coinsurance Not Covered -----------------none-------------------------
Sample of an HMO SBC Regarding Outpatient & Inpatient Benefits
Outpatient Surgery & Hospital Stay separate Facility fees and Physician fees benefits for this example both are at a coinsurance level. Some plans will providea copay at the Facility fee level benefit
3434
Sample of An UnitedHealthcare SBC Single Individual Family Deductible
Important Questions Answers Why this Matters:
What is the overall deductible?
Are there other deductibles for specific services?
Is there an out–of– pocket limit on my expenses?
$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.
Yes. $500 per person per calendar year for Tiers 2-4 outpatient prescription drugs. There are no other specific deductibles.
Yes. $6,350 per person and $12,700 per family per calendar year. Other limits apply – see the chart that starts on page 2.
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.
You must pay all the costs for these services up to the specific deductible amount before this plan begins to pay for these services.
The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses.
Notice UHC does not provide a Family Deductible level. Each family membermust meet a $5000 per person Deductible before coinsurance applies
3535
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
If you have mental health, behavioral health, or substance abuse needs
Mental/ Behavioral health outpatient services
Standard $60 copayment/ visit
Enhanced* $40 copayment/ visit
Not Covered
Early Intervention Services are limited to 45 visits per year.
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
Standard 35% coinsurance/admission
Enhanced* 35% coinsurance/admission
Not Covered
Preauthorization required.
Substance use disorder outpatient services
Standard $60 copayment/ visit
Enhanced* $40 copayment/ visit
Not Covered
Preauthorization required.
Substance use disorder inpatient services
Standard 35% coinsurance/admission
Enhanced* 35% coinsurance/admission
Not Covered
Preauthorization required.
3636
Sample Kaiser Permanente’s SBC Rehabilitation Benefits
Common Medical Event
Services You May Need
Your Cost If You Use a Plan
Provider
Your Cost If You Use a Non-Plan
Provider
Limitations & Exceptions
If you need help recovering or have other special health needs
Home health care 40% coinsurance Not covered Limited to less than 8 hours per day and 28 hours per week
Rehabilitation services
40% coinsurance for outpatient services; See Facility fee under "If you have a hospital stay" for inpatient services.
Not covered
Combined outpatient visit limit between rehabilitation and habilitation services of 40 visits per therapy per year (autism spectrum disorders are not subject to the visit limit); Inpatient in a multi-disciplinary facility limited to 60 days per condition per year.
Habilitation services
40% coinsurance for outpatient services
Not covered
Combined outpatient visit limit between rehabilitation and habilitation services of 40 visits per therapy per year (autism spectrum disorders are not subject to the visit limit).
Skilled nursing care 40% coinsurance Not covered Limited to 100 days per year Durable medical equipment
40% coinsurance
Not covered
Coverage is limited to items on our DME formulary. Prosthetic arms and legs at 20% coinsurance (not subject to the deductible).
Hospice service 40% coinsurance Not covered ---none---
3737
Sample of The SBC’s Excluded & Other Covered Services Section
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
Bariatric surgery
Cosmetic surgery, unless to correct a functional impairment caused by injury, infection, disease
Child glasses
Child dental check up
Dental care (Adult)
Infertility treatment
Long- term care
Non-emergency care when traveling outside the U.S. except as required by law for emergency care
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.)
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
This section could vary by carrier & plan type, notice the disclaimer “ Check your policy or plan document”
3838
Each SBC Provides A Coverage Sample
Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540
Deductibles $100 Co-pays $600 Co-insurance $300 Limits or exclusions $80
Total $1,080
Deductibles $1,000 Co-pays $20 Co-insurance $1,300 Limits or exclusions $200 Total $2,520
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.
Having a baby (normal delivery)
Amount owed to providers: $7,540 Plan pays $5,020 Patient pays $2,520
Sample care costs:
Patient pays:
Managing type 2 diabetes (routine maintenance of
a well-controlled condition)
Amount owed to providers: $5,400 Plan pays $4,320 Patient pays $1,080
Sample care costs: Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400
Patient pays:
39
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
4040
C4HCO Carrier Partners' by Market
Carrier Consumer Facing Name / DBA TIndividual Health Plans Group Health Plans Dental Individual Plans Dental Group Plans
Access Health Colorado H X Colorado Choice Health Plans H X X Colorado HealthOP H X X Denver Health Medical Plan H X Humana H X Kaiser Permanente H X X Rocky Mountain Health Plans H X X SeeChange Health H X UnitedHealthcare / All Savers H X Anthem Blue Cross & Blue Shield / HMO Colorado B X X X XCigna B X X
Best Life & Health Insurance CompanyD X X
Delta Dental of Colorado D X XDentegra Insurance Company D X XGuardian D XPremier Access Dental & Vision D X XMetLife D X
Total by Participation 10 6 6 7
41
SHOPSmall 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
4242
Small Group Market
Company ( * Trading Partners)Level of
Coverage* Off the Market Place On the Market Place Grand Total
Colorado Choice * Bronze 3 3 6
Gold 3 3 6
Silver 6 4 10
Colorado HealthOP * Bronze 2 2 4
Gold 2 2 4
Silver 2 2 4
Anthem * Bronze 11 1 12
Gold 26 2 28
Platinum 2 2
Silver 30 2 32
Kaiser Permanente * Bronze 9 9 18
Gold 15 6 21
Silver 19 9 28
Rocky Mountain Health Plans * Bronze 12 12 24
Gold 12 12 24
Silver 20 20 40
SeeChange * Bronze 5 1 6
Gold 1 1 2
Silver 3 1 4
UnitedHealthcare Bronze 12 12
Gold 23 23
Platinum 4 4
Silver 44 44
Grand Total 266 92 358
4343
Small Group Medical Plans On & Off the Market Place
65% More Plans OFF the Market Place
Off the Market Place On the Market Place
266
92
4444
Small Group Market by Carrier
Colora
do Choic
e
Colora
do Hea
lthOP
Anthem
Kaise
r Per
man
ente
Rocky
Mounta
in H
ealth
Pla
n
SeeChan
ge
UnitedHea
lthca
re
126
58
43 44
9
71
106 4
24
44
30
Off the Market Place On the Market Place
4545
Small Group Market by Metal Tier
48% more Bronze Plans
69% more Silver Plans
68% more Gold Plans
Bronze Silver Gold Platinum Total
54
124
82
6
266
28 3826
0
92
Off the Market Place On the Market Place
4646
Small Group Medical Plans On & Off the Market Place by Product Type
EPO HMO POS PPO
23
124
42
77
0
67
0
25
23
191
42
102
Off the Market Place On the Market Place Grand Total
4747
SHOP Silver Rate Comparison Plans ON the Market Place
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
Rates Based on a 27 Year Old
4848
SHOP Rating Area Comparison Low End Plans State Wide Carriers Only
Plans ON The Market Place Area 1 Area 2 Area 3 Area 4 Area 5 Area 6 Area 7 Area 8 Area 9 Area 10 Area 11
Boulder CoSpr DenverFt
CollinsGrand
Junction Greeley Pueblo S East N East West Resort
Company Plan Low Low Low Low Low Low Low Low Low Low Low
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 HMO $325.79 $252.42 $284.71 $355.15 $252.42 $340.47 $325.79 $311.12 $399.17 $296.45 $410.91 39%RMHP Statewide Network 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%
Rates Based on a 27 Year Old
Small Group Silver Plans
4949
Plans ON The Market Place 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 CollinsGrand
Junction Greeley Pueblo S East N East West Resort
Company Plan High High High High High High High 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 HMO $339.42 $262.97 $296.60 $370.00 $262.97 $354.71 $339.42 $324.13 $415.87 $308.84 $428.10 39%RMHP Statewide Network 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%
SHOP Rating Area Comparison High End Plans State Wide Carriers Only
Rates Based on a 27 Year Old
Small Group Silver Plans
5050
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
Plans ON the Market PlaceColorado Springs average 25% difference between the lowest & highest price planDenver average 30% difference between the lowest & highest price planFort Collins average 47% difference between the lowest & highest price plan
Plan Types 191 HMO, 102 PPO, 42 POS, 23 EPO
Most C4HCO carriers offer equal rates ON & OFF the Market Place, except KP offers 2% lower ratesfor 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%
51
IndividualMarket Analysis
This is a representative sample of the Carrier's plans and rates.It is not intended to promote one Carrier over another Carrier
5252
Individual Market (section 1)
Company ( * Trading Partners)
Level of Coverage*Off the Market
PlaceOn the Market
Place Grand Total
UnitedHealthCare All Savers *
Bronze 2 2
Catastrophic 1 1
Gold 2 2
Platinum 1 1
Silver 3 3
Cigna *Bronze 3 3 6
Gold 3 3 6
Silver 5 5 10
Colorado Choice *
Bronze 3 3 6
Catastrophic 1 1 2
Gold 3 3 6
Silver 5 5 10
Colorado HealthOP *
Bronze 2 2 4
Catastrophic 2 2
Gold 2 2 4
Silver 2 2 4
Denver Health Medical *
Gold 2 2
Silver 2 2
Anthem *
Bronze 6 6 12
Catastrophic 1 1 2
Gold 2 2 4
Silver 6 5 11
5353
Individual Market (section 2)
Company ( * Trading Partners)
Level of Coverage*Off the Market
PlaceOn the Market
Place Grand Total
Kaiser Permanente *
Bronze 9 9 18
Catastrophic 3 3 6
Gold 6 6 12
Silver 9 9 18
Access Health Colorado *
Bronze 2 2
Gold 2 2
Silver 2 2
Rocky Mountain Health Plans*
Bronze 14 20 34
Catastrophic 2 4 6
Gold 2 4 6
Silver 16 24 40
Time Insurance Company
Bronze 14 14
Catastrophic 2 2
Gold 4 4
Platinum 4 4
Silver 8 8
Humana *
Bronze 8 2 10
Catastrophic 4 1 5
Gold 1 1 2
Platinum 1 1 2
Silver 8 2 10
Grand Total 159 150 309
5454
Individual Medical Plans On & Off the Market Place
6% More Plans OFF the Market Place
Off the Market Place On the Market Place
159
150
5555
Individual Market by Carrier
UnitedHea
lthCar
e All
Saver
s
Cigna
Colora
do Choic
e
Colora
do Hea
lthOP
Denve
r Hea
lth M
edic
al
Anthem
BC& B
S
Kaise
r Foundat
ion H
ealth
Pla
n
Acces
s Hea
lth C
O
Rocky
Mounta
in H
ealth
Pla
n
Time
Insu
rance
Human
a
0
11 126
0
15
27
0
34 32
22
911 12
84
14
27
6
52
07
Off the Market Place On the Market Place
5656
Individual Market by Metal Tier
Catastrophic Bronze Silver Gold Platinum Total
13
59 59
23
5
159
13
4959
27
2
150
Off the Market Place On the Market Place
5757
Individual Medical Plans On & Off the Market Place by Product Type
EPO HMO POS PPO
3
77
10
69
13
98
0
39
16
175
10
108
Off the Market Place On the Market Place Grand Total
5858
Plans ON The Market Place Colo Springs Denver Fort Collins
Company Plan Low High Low High Low High
United HC / All Savers EPO $312.14 $318.57
Cigna PPO $260.91 $292.65
Colorado Choice HMO $216.55 $223.42 $241.44 $249.10 $293.72 $303.02
COOP (Metro) EPO $223.78 $223.78 $245.75 $245.75
COOP (State) PPO $252.98 $252.98 $257.54 $257.54 $282.80 $282.80
Denver Health closed network HMO $225.37 $225.37
Denver Health Exp network HMO $261.52 $261.52
Anthem / HMO Colorado HMO $245.78 $272.66 $262.17 $290.85 $276.48 $306.73
Anthem / HMO Colorado HMO $245.78 $272.66 $262.17 $290.85 $276.48 $306.73
Humana Health Plan HMO $198.58 $201.44 $205.32 $208.27
Kaiser Permanente DB HMO $201.04 $213.77
Kaiser Permanente N Co HMO $190.99 $203.08
Kaiser Permanente S Co HMO $221.15 $235.14
CO Access / New Ventures PPO $340.80 $345.07 $372.33 $377.00 $405.45 $410.53
RMHP CHP Network HMO $231.57 $255.07 $261.18 $287.70 $325.80 $358.88
RMHP Mesa HMO $233.91 $271.91 $263.83 $306.70 $329.11 $382.58
RMHP NWP Network HMO $224.90 $241.75 $253.67 $272.67 $316.43 $340.14
RMHP Statewide Network PPO $243.71 $283.28 $274.88 $319.51 $342.90 $398.56
Rates Based on a 27 Year Old
Individual Silver Rate Comparison Plans ON the Market Place
5959
Plans ON The Market Place Area 1 Area 2 Area 3 Area 4 Area 5 Area 6 Area 7 Area 8 Area 9 Area 10 Area 11
Boulder CoSpr DenverFt
CollinsGrand
Junction Greeley Pueblo S East N East West Resort
Company Plan Low Low Low Low Low Low Low Low 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 Rating Area Comparison Low End Plans State Wide Carriers Only
Rates Based on a 27 Year Old
Individual Silver Plans
6060
Plans ON The Market Place Area 1 Area 2 Area 3 Area 4 Area 5 Area 6 Area 7 Area 8 Area 9 Area 10 Area 11
Boulder CoSpr DenverFt
CollinsGrand
Junction Greeley Pueblo S East N East West Resort
Company Plan High High High High High High High High High High High
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%
Rates Based on a 27 Year Old
Individual Rating Area Comparison High End Plans State Wide Carriers Only
Individual Silver Plans
6161
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 PlaceColorado Springs average 40% difference between the lowest & highest price planDenver average 48% difference between the lowest & highest price planFort 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 ratesfor plans ON.
For Statewide carriers, Boulder & COS offer the lower rates & the Resort area the Highest at about 40%
62
Dental Small GroupMarket Analysis
This is a representative sample of the Carrier's plans and rates.It is not intended to promote one Carrier over another Carrier
6363
Dental Small Group Market
Company ( * Trading Partners) Level of Coverage*Off the Market On the Market Grand Total
Best Life Insurance Company *High 3 3 6
Low 3 3 6
Delta Dental / Colorado Dental *High 119 3 122
Low 3 1 4
Dentegra Insurance Company *High 3 3 6
Low 3 3 6
Metropolitan Life Insurance Company *High 2 2 4
Low 2 2 4
Premier Access * Low 3 3 6
Renaissance Life and Health IC of AmericaHigh 1 1
Low 1 1
Anthem / Rocky Mountain Hospital and Medical Serv. *
High 6 6 12
Low 9 7 16
See Change Insurance CompanyHigh 1 1
Low 8 8
The Guardian Life *High 4 4 8
Low 7 5 12
Grand Total 178 45 223
6464
178
45
Small Group Dental Plans On & Off the Market Place
75% More Plans OFF the Market Place
Delta Dental has 97% More Plans OFF the Market Place
6565
Small Group Dental Plans On & Off the Market Place by Product Type
Off the Market Place On the Market Place Grand Total
139
21
160
39
24
63
178
45
223
High Low Total
6666
Small Group Market by Carrier
Best Life
Delta D
ental
Dentegra
Met L
ife
Prem
ier A
ccess
Renaissance L
ife
Anthem
SeeChange
Guard
ian
6
22
64
32
17
911
64
64
3
0
13
0
9
Off the Market Place On the Market Place
67
Dental IndividualMarket Analysis
This is a representative sample of the Carrier's plans and rates.It is not intended to promote one Carrier over another Carrier
6868
Dental Individual Market
CompanyLevel of
Coverage*
Off the Market
On the Market
Grand Total
Best Life Insurance CompanyHigh 3 3 6
Low 3 3 6
CIGNA Low 1 2 3
Delta Dental / Colorado DentalHigh 3 3 6
Low 1 2 3
Dentegra Insurance CompanyHigh 3 3 6
Low 3 3 6
Premier Access Low 3 3 6
Renaissance Life and Health IC of AmericaHigh 2 2
Low 2 2
Anthem High 2 2
Low 2 2
Grand Total 28 22 50
6969
Individual Dental Plans On & Off the Market Place
18% More Plans OFF the Market Place
Small Group has 77% More Plans than the Individual Market
Off the Market Place On the Market Place
28
22
7070
Individual Market by Carrier
6
1
4
6
3
4 4
6
2
5
6
3
0 0
Off the Market Place On the Market Place
7171
Individual Dental Plans ON & OFF the Market Place by Product Type
Off the Market Place On the Market Place Grand Total
139
22
15 13
2828
22
50
High Low Total
72
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
7373
Cost-Sharing and Metal Tiers
ACA Precious Metal Tiers
Plan TierActuarial
Value
Platinum 90%
Gold 80%
Silver 70%
Bronze 60%
In general, lower member cost-sharingand higher premiums
In general, higher member cost-sharingand lower premiums
Actuarial valuepercentages representhow much of a typicalpopulation’s medicalspending a healthinsurance plan would cover.
7474
Access Health ColoradoBenefits Bronze PPO Silver PPO Gold PPO
Ded Individual $5,000 $10,000 $4,000 $8,000 $2,000 $4,000Ded Family $10,000 $20,000 $8,000 $16,000 $4,000 $8,000OOPMax Ind $6,350 $12,700 $6,350 $12,700 $4,000 $8,000OOPMax Family $12,700 $25,400 $12,700 $25,400 $8,000 $16,000
Primary Care 40% Coin After Ded 50% Coin After Ded $25 Copay 50% Coin After Ded $10 Copay 40% Coin After Ded
Specialist visit 40% Coin After Ded 50% Coin After Ded $50 Copay 50% Coin After Ded $20 Copay 40% Coin After Ded
Prevention visit No Charge $0 Copay 50% Coin After Ded No Charge $0 Copay 50% Coin After DedNo Charge $0
Copay 40% Coin After Ded
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 40% Coin After Ded 50% Coin After Ded 30% Coin After Ded 50% Coin After Ded 20% Coin After Ded 40% Coin After DedEmergency visit 40% Coin After Ded 40% Coin After Ded $250 Copay $250 Copay $250 Copay $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 30% Coin After Ded 50% Coin After Ded 20% Coin After Ded 40% Coin After DedPremium $302.59 $386.19 $448.94
% increase Lowest Plan 22% 33%
Benefit Comparison By Metal Tier Access Health Colorado Sample
7575
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 30% Coin After Ded 35% Coin After Ded 0% Coin After Ded
Urgent Care 0% Coin After Ded $50 Copay / 30% Coin AD $50 Copay / 35% Coin AD $50 Copay / 0% Coin AD
Premium $188.27 $221.81 $291.12 $372.82
% increase Catastrophic Plan 15% 35% 50%
Benefit Comparison By Metal Tier Anthem BC/BS Sample
No Rx Deductible
7676
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 DedNo 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 DedNo Charge $0
Copay 50% Coin After Ded
Prevention visit No Charge $0 Copay No Charge $0 Copay No Charge $0 Copay 50% Coin After DedNo Charge $0
Copay 50% Coin After Ded
Diagnostic Test 40% Coin After Ded 50% Coin After Ded 30% Coin After Ded 50% Coin After DedNo Charge $0
Copay 50% Coin After Ded
Imaging 40% Coin After Ded 50% Coin After Ded 30% Coin After Ded 50% Coin After DedNo Charge $0
Copay 50% Coin After Ded
Generic Drugs $4 Copay Not Covered $4 Copay Not CoveredNo Charge $0
Copay Not Covered
Non-Preferred G 40% Coin After Ded Not Covered $20 Copay Not CoveredNo Charge $0
Copay Not Covered
Preferred Drugs 40% Coin After Ded Not Covered $60 Copay Not CoveredNo 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 CoveredNo Charge $0
Copay Not Covered
Facility Outpatient 40% Coin After Ded 50% Coin After Ded 30% Coin After Ded 50% Coin After DedNo Charge $0
Copay 50% Coin After Ded
Facility Inpatient 40% Coin After Ded 50% Coin After Ded 30% Coin After Ded 50% Coin After DedNo Charge $0
Copay 50% Coin After Ded
Emergency visit 40% Coin After Ded 40% Coin After Ded 30% Coin After Ded 50% Coin After DedNo Charge $0
Copay 50% Coin After Ded
Emergency Trans 40% Coin After Ded 50% Coin After Ded 30% Coin After Ded 50% Coin After DedNo Charge $0
Copay 50% Coin After Ded
Urgent Care $75 Copay 50% Coin After Ded $75 Copay 50% Coin After DedNo Charge $0
Copay 50% Coin After Ded
Premium $238.68 $270.62 $312.43
% increase Lowest Plan 12% 24%
Benefit Comparison By Metal Tier Cigna Plan Sample
7777
Colorado Choice Health Plan
Benefits Bronze Choice 3000/50 Silver Choice 2000/Copay Gold Choice 1500/20
Ded Individual $3,000 $2,000 $1,500
Ded Family $6,000 $4,000 $3,000
OOPMax Ind $6,350 $6,350 $4,000
OOPMax Family $12,700 $12,700 $8,000
Primary Care 50% Coin After Ded $20 Copay $15 Copay
Specialist visit 50% Coin After Ded $40 Copay $25 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 20% Coin After Ded
Imaging 50% Coin After Ded $150 Copay 20% Coin After Ded
Generic Drugs $25 Copay $15 Copay $10 Copay
Preferred Drugs 50% Coin After Ded $40 Copay $35 Copay
Non-Preferred 50% Coin After Ded $60 Copay $60 Copay
Specialty Drugs 50% Coin After Ded $60 Copay 20% Coin Ded Waived
Facility Outpatient 50% Coin After Ded 40% Coin After Ded 20% Coin After Ded
Facility Inpatient 50% Coin After Ded 40% Coin After Ded 20% Coin After Ded
Emergency visit 50% Coin After Ded $150 Copay After Ded $150 Copay
Emergency Trans 50% Coin After Ded $100 Copay After Ded 20% Coin After Ded
Urgent Care 50% Coin After Ded 40% Coin After Ded 20% Coin After Ded
Premium $206.08 $261.20 $292.59
% increase Catastrophic Plan 21% 30%
Benefit Comparison By Metal Tier Colorado Choice Health Plan Sample
7878
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
Premium $173.01 $232.10 $276.42
% increase Catastrophic Plan 25% 37%
Benefit Comparison By Metal Tier Colorado HealthOP Plan Sample
7979
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 CopayFacility 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 13% 14% 13%
Benefit Comparison By Metal Tier Denver Health Medical Sample
8080
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
Generic Drugs $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
Urgent Care $100 Copay $50 Copay $50 Copay $50 Copay
Premium $202.41 $212.96 $242.90 $273.85
% increase Catastrophic Plan 5% 17% 26%
Benefit Comparison By Metal Tier Humana Sample
8181
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
Urgent Care $100 Copay $75 Copay $75 Copay
Premium $193.68 $214.79 $244.82
% increase Catastrophic Plan 10% 21%
Benefit Comparison By Metal Tier Kaiser Permanente Plan Sample
8282
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
Primary Care $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
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
Premium $233.31 $263.11 $365.79
% increase Lowest Plan 11% 36%
8383
Benefit Comparison By Metal Tier UnitedHealthcare Sample
UnitedHealthcare / All Savers Individual Plans
Benefits Catastrophic Plan Copay Bronze Plan Copay Silver Plan C Copay Gold Plan C Copay Plan Platinum
Ded Individual $6500 per person $5500 per person $5000 per person $1500 per person $500 per person
Ded Family N/A N/A N/A N/A N/A
Ded Rx Ind N/A N/A $500 per person T2-4 $150 per person T2-4 N/A
Ded Rx Family N/A N/A N/A N/A N/A
OOPMax Ind $6,350 $6,350 $6,350 $3,200 $1,500
OOPMax Family $12,700 $12,700 $12,700 $6,400 $3,000
Primary Care 3 OV per person $50 Copay / 20% Coin $35 Copay / 20% Coin $20 Copay / 20% Coin $10 Copay / 10% Coin
Specialist visit No Charge after Ded $100 Copay / 20% Coin $60 Copay / 20% Coin $40 Copay / 20% Coin $20 Copay / 10% Coin
Prevention visit No Charge $0 Copay No Charge $0 Copay No Charge $0 Copay No Charge $0 Copay No Charge $0 Copay
Diagnostic Test No Charge after Ded 20% Coin 20% Coin 20% Coin 10% Coin
Imaging No Charge after Ded 20% Coin 20% Coin 20% Coin 10% Coin
Generic Drugs No Charge after Ded 20% Coin $15 Copay $15 Copay $10 Copay
Preferred Drugs No Charge after Ded 20% Coin $40 Copay/After Ded $35 Copay/After Ded $35 Copay
Non-Preferred No Charge after Ded 20% Coin $80 Copay/After Ded $70 Copay/After Ded $60 Copay
Specialty Drugs No Charge after Ded 20% Coin 25% of nego. Rate / AD $250 Copay/After Ded $250 Copay
Facility Outpatient No Charge after Ded 20% Coin 20% Coin 20% Coin 10% Coin
Facility Inpatient No Charge after Ded 20% Coin 20% Coin 20% Coin 10% Coin
Emergency visit No Charge after Ded 20% Coin 20% Coin $300 Copay $250 Copay
Emergency Trans No Charge after Ded 20% Coin 20% Coin $300 Copay 10% Coin
Urgent Care No Charge after Ded 20% Coin 20% Coin $75 Copay $75 Copay
Premium $288.49 $322.22 $343.75 $395.19 $470.62
% increase Catastrophic Plan 10% 16% 27% 39%
84
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
8585
• Colorado has 11 rating areas based on varies countieso 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
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
Colo Springs
Denver
Fort Collins Grand Junction
Greeley
Pueblo
SouthEast
NorthEast
West
Resort
Boulder County El Paso Teller
Adams Arapahoe
Broomfield Clear Creek
Denver Douglas Elbert Gilpin
Jefferson Park
Larimer Mesa Weld Pueblo Baca Bent
Cheyenne Crowley Custer Frmont
Huerfano Kiowa
Kit Carson Las Animas
Lincoln Mineral Otero
Prowers Alamosa Chaffee Conejos Costilla
Rio Grande
Logan Morgan Phillips Sedwick
Washington Yuma
Archuleta Delta
Dolores Grand
Gunnison Hinsdale Jackson La Plata
Lake Moffat
Montezuma Montrose
Ouray Rio Blanco
Routt San Juan
San Miguel
Eagle Garfield Pitkin
Summit
Saguache
Colorado Rating Areas by County
8686
Colorado Rating Area Map
10
115
1
2
3
4 6
78
9
10
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 )
8
8787
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 youService Area• Statewide Coverage
8888
Anthem BlueCross and BlueShield Individual & Small Group Market
Unique Offerings and ProgramsOnce 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
8989
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
9090
Cigna Individual Service Area
Cig
na
Cigna
Cigna
Cigna
Cigna
Cigna
9191
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
organizationsPilot 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 populationsService Area:• No Statewide, 30 counties & 6 rating areas
9292
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
CO Choice
CO Choice
CO Choice CO Choice
CO ChoiceCO Choice
9393
Colorado HealthOP Individual & Small Group Market
Unique Offerings and ProgramsColorado 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
9494
Colorado HealthOP Central Metro Network (EPO)
COOP
COOP
COOP
COOP
COOP
COOP
COOP
COOP
COOP
COOP
COOP
COOP
COOPCOOP
COOP
COOP
COOP
9595
Denver Health Medical Plan / ELEVATE Individual Market
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 health-related goals, like quitting smoking and weight loss.
Service Area• No Statewide coverage limited to 3 counties & 1 rating area
9696
Denver Health Medical Plan / ELEVATE Service Area
DH DHDH
9797
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
9898
Humana Service Area
Humana Humana
Humana
Humana
Humana
Humana
Humana
Hum
ana
9999
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, patient-centered 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
100100
Kaiser Permanente Service Area
KPDB
KPDB
KPDB
KPDB
KPDB
KPDB KPDB
KPDBKPDB
KPDB
KPDB
KPDB
KPDB KPDB
KPNC
KPCS
KPCS
KPCS
KPCS
KPCS
KPCS
KPCS
KPCS
KPCS
101101
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
102102
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 reimbursementWhen preventive Health Actions uncover specific chronic conditions members can earn more rewards for completing additional Health Actions aimed at helping them manage those conditions.
Service Area – Statewide coverage
103103
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)
104104
UHC
UHC
UHC
UHC
UHC
UHC
UHC
UHC
UHC
UHC
UHCUHC
UHC
UHC
UHC
UHC
UHC
UHC
UHC
UHC
UHCUHC
UHC
UHC
UHC
UHC
UHC
UHC
UHC
UHCUHC
UHC
UHC
UHC
UHC
UHC
UHC
UHC
UHC
UHC
UHC
UHC
UHC
UHC
UHC
UHC
United HealthCare / All Savers IndividualService Area