Health Plan Market &

Benefit Comparison Part I Presented by Cliff CraigHealth Plan Account Manager for Connect for Health Colorado

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Key Topics to be Discussed

• Review Basic Insurance Terminology

• Key Things to Consider When Distinguishing Between Carriers & Benefit Coverage

• Understanding Plan Benefits & Summary of Benefits and Coverage (SBC)

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Review Basic Insurance Terminology

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Simple Terms And Definitions

• Monthly Premium – The monthly amount that you must pay for your health / dental insurance (coverage)

• Annual Deductible - You need to pay this amount before your plans starts helping you pay for most covered services through coinsurance. You may have to cover some costs that will not count toward this total deductible.

• Annual Out of Pocket Limit - This is the most you’ll pay for care during a policy period (usually a year) before your plan starts paying 100 percent for most covered services.

• Copay - A fixed amount (for example, $15) you pay for a medical visit or for medication that is covered under your health plan, usually when you receive the service. This is considered part of your out-of-pocket costs, separate from premiums and deductibles.

• Coinsurance - After reaching your deductible, you may start paying a percentage of the total cost for certain services. Coinsurance usually reflects the percentage of medical expenses that you are responsible to cover, for dental expenses the percentage reflects what the dental plan will cover.

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• In Network (Tier 1) –What you pay for covered health care services to providers who are contracted with your health insurance or plan. In-network benefits cost you less than out-of-network benefits.

• Out of Network – The benefits levels you pay for covered health care services to providers who are NOT contracted with your health insurance or plan. Out of network benefits cost are much higher than In-network benefits.

• Summary of Benefits and Coverage (SBC) – This document will help consumers better understand the coverage they have and, for the first time, allow them to easily compare different coverage options. It will summarize the key features of the plan or coverage, such as the covered benefits, cost-sharing provisions, and coverage limitations and exceptions. People will receive the summary when shopping for coverage, enrolling in coverage, at each new plan year, and within seven business days of requesting a copy from their health insurance issuer or group health plan.

Simple Terms And Definitions

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Annual Deductible

• You need to pay this amount before your plan starts helping you pay for most covered services through coinsurance.

• Most plans Copays do not apply and are not dependent on the Deductible.• Family Deductibles are normally 2 times the Individual Deductibles.• Deductibles accumulate on a calendar year, Jan. 1st to Dec. 31st.• Deductibles could or could not apply to the Out-of-Pocket Limit.• Once Copays, Coinsurance, Deductible & Out-of-Pocket Limit reach the Maximum

Out-of-Pocket limit $6,350 individual / $12,700 family for a calendar year the Plan pays 100%

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.

$4,500 person/ $9,000 family Does not apply to preventive services, certain services with copays and prescription drugs.

What is the overall deductible?

Are there other deductibles for specific services?

Prescription drugs: $ 500 person in network. There are no other specific deductibles.

You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these services.

Sample from a SBC document:

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Annual Out of Pocket Limit

• This is the most you’ll pay for care during a policy period (usually a year) before your plan starts paying 100 percent for most covered services.

• Family Out-of-Pocket Limits are normally 2 times the Individual Out-of-Pocket Limits.• Out-of-Pocket Limits accumulate on a calendar year, Jan. 1st to Dec. 31st.• In the sample below the plan would pay 100% for coinsurance after the $5,200 /

$10,400, the member will still pay for copays up to the $6,350 / $12,700 limit• Remember once Copays, Coinsurance, Deductible & Out-of-Pocket Limit reach the

Maximum Out-of-Pocket limit $6,350 individual / $12,700 family for a calendar year the Plan pays 100%o Rx copays & deductibles are included in the Maximum Out-of-Pocketo Maximum Out-of-Pocket Limit applies to In-Network services ONLY

Sample from a SBC document:

Is there an out–of– pocket limit on my expenses?

What is not included in the out–of–poc ket limit?

For preferred providers $5,200 person / $10,400 family

Premiums, balance billed charges and health care this plan doesn't cover.

The out-of-poc ket 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.

Even though you pay these expenses, they don't count toward the out-of- pocket limit.

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Copay & Coinsurance

CopayA fixed amount (for example, $15) you pay for a medical visit or for medication that is covered under your health plan, usually when you receive the service. This is considered part of your out-of-pocket costs, separate from premiums and deductibles. • There may be separate copays for different services: Primary care, Specialist,

Preventive care, Hospitalization, Emergency Room etc…• Some plans require that a deductible first be met for some specific services before

a copayment applies

CoinsuranceAfter reaching your deductible, you may start paying a percentage of the total cost for certain services. Coinsurance usually reflects the percentage of medical expenses that you are responsible to cover, for dental expenses the percentage reflects what the dental plan will cover.

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Allowed Amount & Balance Billing

Allowed AmountMaximum amount on which payment is based for covered health care services. This may be called “eligible expense,” “payment allowance” or “negotiated rate.”

Balance BillingWhen a provider bills you for the difference between the provider’s charge and the Allowed Amount. For example, if the provider’s charge is $100 and the allowed amount is $70, the provider may Balance Bill you for the remaining $30. A preferred provider, one that is participating in your insurance company’s provider network, can not Balance Bill you for covered services.

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Copay & Coinsurance / Allowed Amount & Balance Billing

Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan’s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven’t met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) This plan may encourage you to use preferred providers by charging you lower deductibles, copayments and coinsurance amounts.

Sample from a SBC document:

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Key Things to Consider When Distinguishing

Between Carriers & Benefit Coverage

Shopping Readiness

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Key Questions That Influence An Individual’s Shopping Decisions

• What is most important to the person who is looking for a plan?o Are they currently insured? Happy with your current carrier?o Low premium? Low cost-sharing charges?o Providers or Hospital?

• What does their budget allow for health coverage? o Is the person eligible for premium credits or cost-sharing reductions?

• This may make some coverage tiers (i.e., Silver) more attractive.

• What health care does the person expect to use during the year?o Do you have a medical conditions? o Are you or any family member attached to seeing a particular physician?

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Choosing Your Current Carrier

• Is your current carrier offering plans on the Exchange?o If they wish to stay with their current carrier, now it

becomes a search for similar out of pocket cost for accessing benefits.

• They are currently taking medication, still review the carriers Rx benefit & formulary to confirm the medication is covered at a comfortable out of pocket cost amount.o Formulary is to specify particular medications that are

approved to be prescribed under a particular insurance policy.

o A carriers formulary and drug coverage level can change based on plan type

o Drug coverage levels – Tier 1 Generic, Tier 2 Preferred, Tier 3 Non-Preferred, Tier 4 Specialty Drugs

• If they have a chronic medical condition and are continuing to receive care from a specific physician or facility, check the carriers provider directory. o A carriers networks can change based on plan type.

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Using the Search Functions for Lower Premiums or Lower Cost-sharing

A person can search by:• Provider• Monthly premium• Annual Deductibles

• Individual• Family

• Annual Out-of-Pocket• Individual• Family

• Carrier• Coverage Level

• Metal Tiers

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Advanced Premium Tax Credit (APTC) & Cost Sharing Reduction (CSR) Sample

Actual C4HCO Silver Plan (Based on a 28 year old male, Denver zip code)

 Standard Silver No CSR

CSR Plan 201 - 250% FPL

CSR Plan 150 - 200% FPL

CSR Plan up to 150% FPL

Annual income $35,000 $27,000 $20,000 $17,000

Actuarial Value 70% 73% 87% 94%

Monthly Premium $212.96 $169.30 $85.12 $54.96

APTC Monthly Amount $0.00 $43.66 $127.84 $158.00

Medical Deductible Individual $4,600 $3,250 $900 $500

Medical Deductible Family $9,200 $6,500 $1,800 $1,000

Drug Deductible Individual $1,500 $1,000 $500 $250

Drug Deductible Family $3,000 $2,000 $1,000 $250

Max. Out-of-Pocket Individual $6,300 $4,750 $1,450 $750

Max. Out-of-Pocket Family $12,600 $9,500 $2,900 $1,500

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Do You Have a Medical Conditions?

• Preexisting conditions can no longer be used to deny coverage or be used to increase their premium.o Do you have a specific physician or facility treating you for this condition?o Do you take certain medications to treat the condition?

• The carriers plan benefit page has a link to their formularyo How often do you require testing services? Lab / Radiology ?

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Are You or a Family Member Attached to a Physician?

• OB/GYN? o Primary care physicianso Primary care copay

• Children's Pediatrician? o Primary care physicianso Primary care copay

• Specialist?o Specialist visit copay o A person could have had a heart condition 10 years ago, but continues to see his

Cardiologist once a year for a check upo Some plans may require a Primary care referral to access a Specialist

• Hospitals can also play an important roleo In their neighborhoodo Easy access

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What Three Factors influence's my premiums? Your Age, Tobacco Use, Location

Your age o Rates from 0 to 20 years have the same rate factor, rates for 21 year old to 65

plus year old the rate factors increase every yearTobacco Use

o Most plans (not all) increase their rates for tobacco usero Any tobacco use more than 4 times a week over the past 6 months (smoking,

electronic cigarettes & chew), but it excludes any tobacco use for religious or ceremonial reasons

Your individual rate is based on zip code & countyo Colorado has 11 rating areas based on varies counties, determined by the DOIo If your coverage is through your employer, the rate is based on the

employer’s zip code & county

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Actual C4HCO Silver Plan Sample Rates Denver market

Age Rate SM Rate Age Rate SM Rate Age Rate SM Rate Age Rate SM Rate

20 $129.52 $129.52 32 $241.30 $277.50 44 $284.95 $327.70 56 $475.88 $547.26

21 $203.98 $234.57 33 $244.36 $281.02 45 $294.54 $338.72 57 $497.09 $571.65

22 $203.98 $234.57 34 $247.63 $284.77 46 $305.96 $351.86 58 $519.73 $597.69

23 $203.98 $234.57 35 $249.26 $286.65 47 $318.81 $366.64 59 $530.95 $610.59

24 $203.98 $234.57 36 $250.89 $288.52 48 $333.50 $383.53 60 $553.59 $636.63

25 $204.79 $235.51 37 $252.52 $290.40 49 $347.98 $400.18 61 $573.17 $659.15

26 $208.87 $240.20 38 $254.15 $292.28 50 $364.30 $418.95 62 $586.02 $673.93

27 $213.77 $245.83 39 $257.42 $296.03 51 $380.41 $437.48 63 $602.14 $692.46

28 $221.72 $254.98 40 $260.68 $299.78 52 $398.16 $457.88 64 $611.92 $703.71

29 $228.25 $262.49 41 $265.58 $305.41 53 $416.11 $478.53 65 + $611.92 $703.71

30 $231.51 $266.24 42 $270.27 $310.81 54 $435.49 $500.81      

31 $236.41 $271.87 43 $276.80 $318.31 55 $454.87 $523.10      

Age 20 to 21 = 37% increaseOther ages vary from 1.3% up to 4.5%Non tobacco to tobacco user 13% increase

Anyone over 65 wouldreceive the same rate

Age 21 to 65 has a 67% increase

2020

Colorado has 11 rating areas based on varies countiesRating Area 1 & 2 have the lowest rates & Rating Area 11 the highest (rates average about 40% difference)Some zip codes will cross multiple counties

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

What Three Factors influence my premiums? Your Age, Tobacco Use, Location

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Understanding Plan Benefits & Summary of Benefits and Coverage (SBC)

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Actuarial Value & Metal Tiers

What Does Actuarial Value Mean? (Risk sharing between Carrier & members)• The actuarial value of a plan tells you what percentage of health care costs that health insurance plan is

expected to pay for its beneficiaries. A plan with an actuarial value of 60 percent (Bronze) is expected to pay approximately 60% of the health care costs of its beneficiaries. The plan’s beneficiaries will pay the other 40% of their health care costs in the form of deductibles, coinsurance and copayments.

• Actuarial value is calculated for the health plan as a whole, not for individual members. So, on average across all of a health plan’s subscribers, the actuarial value describes the percentage of health care expenses that will be paid by the plan. However, the percentage of your health care expenses the plan will pay will vary depending on how you use your health insurance. In general:o If you are a LOW health care utilizer and want a plan to cover you for prevention or in case of an emergency –

Bronze planso If you are a HIGH healthcare utilizer – Gold or Platinum plans

Metal Tiers• Bronze plans 60% / Silver plans 70% / Gold plans 80% / Platinum plans 90%• Catastrophic (CYA) plans are for individuals under the age of 30 OR get a "hardship exemption"

from the Federal Government.o Meet all of the requirements applicable to other Qualified Health Plans (QHPs) but that don't cover

any benefits other than 3 primary care visits per year before the plan's deductible is met. The premium amount you pay each month for health care is generally lower than for other QHPs, but the out-of-pocket costs for deductibles are generally higher ($6350 / $12700).

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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.

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Benefit Comparison By Metal Tier

Actual C4HCO Carrier Individual Plans

Benefits Catastrophic Plan Copay Bronze Plan Copay Silver Plan Copay Gold Plan Copay Platinum Plan

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 $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%

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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)

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Benefits Silver HMO Silver PPO  In Network In Network Out of Network

Ded Individual $1,500 $5,000 $12,500Ded Family $3,000 $10,000 $25,000Rx Ded Individual $250 per person N/A N/ARx Ded Family N/A N/A N/AOOPMax Ind $6,350 $5,000 $25,000OOPMax Family $12,700 $10,000 $50,000Primary Care $30 Copay $30 Copay 50% CoinsuranceSpecialist visit $50 Copay $60 Copay 50% CoinsurancePrevention visit 100% covered 100% covered 100% coveredDiagnostic Test 30% Coinsurance 100% covered After Ded 50% CoinsuranceImaging $250 Copay 100% covered After Ded 50% CoinsuranceGeneric Drugs $15 Copay $4 Copay Not CoveredPreferred Drugs $45 Copay $15 Copay Not CoveredNon-Preferred 30% Coinsurance $45 Copay Not CoveredSpecialty Drugs 30% Coinsurance 50% Coinsurance Not CoveredFacility Outpatient 30% Coinsurance 100% covered After Ded 50% CoinsuranceFacility Inpatient 30% Coinsurance 100% covered After Ded 50% CoinsuranceEmergency visit $350 Copay 100% covered After Ded 50% CoinsuranceEmergency Trans 30% Coinsurance 100% covered After Ded 50% CoinsuranceUrgent Care $75 Copay $75 Copay 50% CoinsurancePremium $221.72 $277.86

% increase Lowest Plan 20%

Benefit Comparison By HMO & PPO Sample

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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

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What Applies to Maximum Out-of-Pocket HMO & EPO Plans

Copayments RxCopayments

Prevention

Deductibles

Coinsurance

Out-of-Pocket Limit

Maximum Out-of-Pocket

$6,350 / $12,700

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What Applies to Maximum Out-of-Pocket PPO Plans

Copayments Deductibles

Coinsurance

RxCopayments

Prevention

In Network Services

Maximum Out-of-Pocket

$6,350 / $12,700

Deductibles

Coinsurance

Out-of-Pocket Max.

Out of Network Services

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Case Study of How Benefits Accumulate for a Individual Policy

Actual C4HCO HMO Silver Plan• Medical Deductible = $2,500 / $5,000 Drug Deductible = $250 Out-of-Pocket Max. = $6,350 / $12,700• PCP visit = $30 Copay / Specialist = $50 Copay • Prescription Drugs = $15 Generic / $45 (After Ded.) Preferred Brand / 30% (After Ded.) Non-Preferred & Specialty• Facilities = 30% Coinsurance (After Ded.) Outpatient / Inpatient Surgery• Emergency Care = $75 Copay Urgent care center / $400 Copay Emergency Room / 30% coin. (After Ded.) Ambul.• Testing = $300 copay CT/PET Scans, MRIs / 30% coinsurance (After Ded.) X-rays / Lab.

John's Medical ServicesCost of services

John's expenses

Applies to Med Ded

Applies to Rx Ded

Applies to OOP max

Carrier expenses

Prevention visit $100 $0 $0 $0 $0 $100PCP visit $80 $30 $0 $0 $30 $50PCP orders meds Preferred $100 $100 $0 $100 $100 $0Specialist visit $150 $50 $0 $0 $50 $100Specialist orders Lab $100 $100 $100 $0 $100 $0Emergency visit $1,000 $400 $0 $0 $400 $600Ambulance ride to ER $1,000 $1,000 $1,000 $0 $1,000 $0ER test MRI $1,500 $300 $0 $0 $300 $1,200ER meds Specialty Drug $150 $150 $0 $150 $150 $0ER med Preferred $145 $45 $0 Ded met $45 $100ER med Generic $115 $15 $0 $0 $15 $100Inpatient Hospital $5,000 $2,480 $1,400 $0 $2,480 $2,520

(John paid $1400 & $1080 (30% of $3600) Ded met      X-rays & Lab $3,000 $900 $0 $0 $900 $2,100Physician surgery $2,500 $750 $0 $0 $750 $1,750Inpt Hosp meds 2 Generics $500 $30 $0 $0 $30 $470Rehab $1,000 $0 $0 $0 $0 $1,000

Total $16,440 $6,350 $2,500 $250 $6,350 $10,090

This plan has a single Rx Deductible even for family. That means

each family member has a $250 Rx

deductible

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Actual C4HCO Catastrophic (CYA) Plan• Medical Deductible = $6,350 / $12,700 Out-of-Pocket Max. = $6,350 / $12,700• PCP visit = $35 Copay (limit 3 per year) Specialist = 100% Out-of-pocket / Prescription Drugs = 100% Out-of-pocket • Outpatient / Inpatient Surgery / Emergency Care / CT/PET Scans, MRIs / X-rays / Lab. = 100% Out-of-pocket

Case Study of How Benefits Accumulate for a Catastrophic (CYA) Policy

All plans cover PreventionAt no cost

All Catastrophic plans cover 3 PCP visits per year not subject to the

Deductible

Bills Medical ServicesCost of sevices

Bill's Expenses

Applies to Med Ded

Applies to OOP max

Carrier expenses

Prevention visit $100 $0 $0 $0 $100PCP visit $80 $35 $35 $35 $50PCP orders meds Preferred $100 $100 $100 $100 $0Specialist visit $200 $200 $200 $200 $0Specialist orders Lab $100 $100 $100 $100 $0Emergency visit $2,000 $2,000 $2,000 $2,000 $0Ambulance ride to ER $1,000 $1,000 $1,000 $1,000 $0ER test MRI $1,500 $1,500 $1,500 $1,500 $0ER meds Specialty Drug $350 $350 $350 $350 $0ER med Preferred $200 $200 $200 $200 $0ER med Generic $50 $50 $50 $50 $0

Total $5,680 $5,535 $5,535 $5,535 $150

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Plan Documents Can Be Used at Decision Points

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

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Shopping Scenario's

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Scenario One

33 year old single male, annual income $50,000 per year• No previous health issues, but a tobacco user, averages $150 a year in medical

expenses• His primary concern is meeting the new regulation & not having a tax penaltyWhat is he eligible for?• APTC or CSR? NO• Catastrophic plans? NOPlans that meet his decision criteria,• Actual C4HCO Bronze HSA ($200.73)

o Ded $5000 / OOP $6350, OV 30% (After Ded), Rx 30% (After Ded)

• Actual C4HCO Bronze HMO (227.65)o Ded $6300 / OOP $6300, OV No Charge (After Ded), Rx No Charge (After

Ded)

• Actual C4HCO Gold HMO ($297.11)o Ded $1600 / OOP $500, OV $15 / $25 copays, Rx $10 / $35 / $60 copays

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Scenario Two

28 year old single female, annual income $22,000 per year• Previous health issues, averages $5500 a year in medical expenses• Her primary concern is accessing medical services with low OOP expensesWhat is she eligible for?• APTC or CSR? APTC = $104.65 per month / CSR 87% • Catastrophic plans? Yes Plans that meet her decision criteria,• Actual C4HCO EPO Catastrophic ($143.78) + Medical expenses ($5350) = ($7075)

o Ded $6350 / OOP $6350, OV $50 for 3 100% (After Ded), Rx No Charge (After Ded)

• Actual C4HCO Bronze HSA ($53.72) + Medical expenses ($5150) = ($5795)o Ded$5000/OOP$6350,OV30%(After Ded)Rx 30%(After Ded)Facility30%(After

Ded)

• Actual C4HCO Silver HMO ($227.65) + Medical expenses ($2250) = ($4982)o Ded $0 / OOP $2250, OV $15/$25 copay, Rx $15/$45/20% Facility 20%

(After Ded)

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Scenario Three

45 year old single male, Native American, annual income $25,000 per year• Previous health issues, averages $5500 a year in medical expenses• His concern is accessing medical services with low OOP expenses & low premium?• APTC or CSR? APTC = $129.60 CSR = 73%• Native American? Yes • Catastrophic plans? NoPlans that meet his decision criteria,• Actual C4HCO Bronze HMO ($92.75)

o Ded $0 / OOP $0, OV 0%, Rx 0%

• Actual C4HCO Silver HMO ($144.07)o Ded $0 / OOP $0, OV No Charge (After Ded), Rx No Charge (After Ded)

• Actual C4HCO Gold HMO ($182.55)o Ded $0 / OOP $0, OV $0 / $0 copays, Rx $0 / $0 / $0 copays

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Key Takeaways & Considerations

Premium isn’t the only consideration in cost

Consider PotentialMedical ExpensesProvider networks

Find the Right MixPremium

Plus Out-of-Pocket

Medical Expenses