Making the right choice crucial for Valley medical insurance shoppers

The Fresno BeeSeptember 7, 2013 

Athena Fleming, information officer of Workforce Connection, talks about the job fair training going on behind her in the Manchester Mall office, where applicants will be hired to staff a call center set up to answer questions regarding Covered California, the state's health benefits exchange.

JOHN WALKER — THE FRESNO BEE Buy Photo

Valley residents will have to consider the cost of health premiums, deductibles and co-payments for doctor visits and prescriptions before they choose a health plan.

Those who don't have insurance through an employer or government program, such as Medicare and Medi-Cal, will be shopping for insurance under the Affordable Care Act, also called Obamacare.

For many, the cost of health plans will be the top concern.

Covered California, the state's health benefit exchange, has an online calculator to estimate health costs, including monthly premiums and out-of-pocket costs. It also has counselors available by telephone at two call centers. A third will open in Fresno in November.

The enrollment window is Oct. 1 through March 31 for the 2014 health plans.

"Most everything you need for Oct. 1 is available now," said Athena Fleming, spokeswoman for Covered California in the Fresno area.

Insurance shoppers likely will need help choosing a health plan.

RELATED: Questions, answers about Obamacare

In Fresno, Kings and Madera counties, three insurance companies — Anthem Blue Cross, Blue Shield and Kaiser Permanente — are offering plans through Covered California. In Merced, Mariposa, Tulare, Stanislaus and San Joaquin counties, Health Net also is a choice.

Each company offers a health plan in four "metal tiers" — silver, bronze, gold and platinum.

Plans in each tier must provide essential services: emergency, ambulatory outpatient, hospital, lab, prescriptions, rehabilitation, preventive and wellness care, maternity and newborn, pediatric and mental health.

Premiums, deductibles and out-of-pocket costs vary by tier.

For example, a bronze-tier plan has the cheapest monthly premium but covers only 60% of health costs on average, and the consumer must shoulder the remaining costs. The silver plan, considered mid-range, covers about 70% of health costs. The gold plan covers about 80% of costs and the platinum, 90%.

Catastrophic plans called "minimum plans" will be available for people younger than 30. The plans have small monthly premiums but an annual deductible of $6,350. They are designed to provide insurance in the event of a massively expensive injury or illness.

For a family to be eligible for the minimum plan, each individual enrolled must be either younger than 30 or provide certification of financial hardship, Fleming said.

About 185,000 people in the Valley may qualify for tax credits to help offset monthly premiums. The amount of tax credit depends on income, age, family size and place of residence.

Individuals or families with incomes between 138% and 400% of the federal poverty level will be eligible for the tax credit. For example, a person who earns $15,900 to $45,960 a year will be eligible. The lower the income, the higher the tax credit.

Here's an example:

Using the Covered California calculator, which asks for age, number of people in house, annual income and ZIP code, the monthly premium can be calculated for a 25-year-old Fresno man earning $17,235 a year — 150% of the federal poverty level.

The calculator shows the man would be:

Eligible for a $171 monthly tax credit.

The tax credit could be used to reduce monthly premiums to no more than $11 for a bronze plan, which covers 60% of health costs, or to a monthly premium of no more than $89 for an enhanced silver plan, which pays 94% of health costs.

The bronze plan would have a $6,350 maximum out-of-pocket cost. The silver plan's maximum out-of-pocket cost would be $2,250.

So far, consumers can compare premiums, deductibles and co-payments through Covered California.

Starting in October, insurance shoppers also will be able to check provider lists to see which doctors and hospitals are participating in the health plans, Fleming said.

"We're finding most people have in mind who they wish their provider to be," and will select their health plan based in part on that, she said.

Access to doctors will be an important consideration, said Jeff Collins, senior vice president and area manager for Kaiser Permanente-Fresno. "In this market, we know price point is a significant factor, but I would just encourage people not to make it the only factor."


How to get help

Call Covered California, the state’s health benefit exchange, at (888) 975-1142, and check out the online calculator at www.coveredca.com.

The reporter can be reached at (559) 441-6310, banderson@fresnobee.com or @beehealthwriter on Twitter.

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