Where does a consumer check for drug formularies?

The health plans that are part of Covered California will have online drug formularies available on their websites.

If an individual has already bought an individual and family high-deductible plan that does not have the essential health benefits, does the individual have to change to a Covered CA plan?

It is our understanding that all individual and family non-grandfathered plans in the private market will be replaced by the carriers with ACA-compliant plans.

How are premium rates based on family composition calculated?

Each family member will be charged based on the premium of their age.  However, health plans can only charge for the three eldest children under 21.  All children age 21 and older are charged premiums based on their age.

What is the difference between individual and Covered California for Small Business plans?

Covered California Health Plans in the Individual Marketplace.

Information on Covered California for Small Business plans can be obtained through PRISM, Claremont’s proprietary quoting system for brokers.

When can you enroll outside of the Marketplace?

A health insurance issuer in the group market must allow an employer to purchase health insurance coverage for a group health plan at any point during the year.
A health insurance issuer in the individual market must allow an individual to purchase health insurance coverage during the initial open enrollment period of Oct. 1, 2013 – March 31, 2014. SB 20, which was signed by the Governor on June 16, 2014-

• Requires health plans and insurers in the individual market to provide an annual enrollment period of November 15, 2014, through February 15, 2015, for the policy year beginning on January 1, 2015, only.
• Requires health plans and insurers in the individual market provide the current annual enrollment period of October 15 through December 7 for policy years beginning on or after January 1, 2016.

Will out-of-pocket maximums include copayments for Rx?

Yes.

What is included in out-of-pocket costs?

Out-of-pocket cost, also called cost-sharing, refers to the amount the consumer pays for covered services at the time they use them. It usually includes:
• Coinsurance (e.g. 20%)
• Co-payments, or similar charges ( e.g. $45/doctor visit)
• Deductibles
Out-of-pocket costs generally do not include:
• Monthly premiums
• Balance billing amounts for out-of-network doctors and hospitals
• The cost of non-covered services or not medically necessary services

Is there a catastrophic plan in Covered California for Small Business?

No, catastrophic plans are only offered through the Individual Marketplace.

What is Essential Community Provider Requirements (Tab 4, slide 19 of 41, in the training binder)?

A Qualified Health Plan (QHP) issuer must have a sufficient number and geographic distribution of essential community providers, where available. Essential community providers are providers that serve predominantly low-income, medically underserved individuals in the QHP’s service area.

For a catastrophic plan, what constitutes not having affordable coverage for those over 30?

If the individual’s required contribution for coverage for the month exceeds 8% of the individual’s household income, then the individual cannot afford coverage.