Choosing the Right Health Insurance Plan
There are 5 categories of Marketplace insurance plans: Bronze, Silver, Gold, Platinum, and Catastrophic.
Plans range from bare bones “bronze” plans which cover 60% of pocket medical costs to “platinum” plans which have greater coverage but come with higher premiums. In general higher premiums mean lower out-of-pocket costs and a wider insurer network of doctors and hospitals.The plans are as listed below:
NOTE: All cost sharing is of out of pocket costs. Please see ObamaCare health benefits for services that are covered at no out of pocket charge on all plans. The maximum out-of-pocket costs for any Marketplace plan for 2014 are $6,350 for an individual plan and $12,700 for a family plan.
Bronze Plan: The bronze plan is the lowest cost plan available. It has the lowest premiums and in exchange has the lowest actuarial value. The actuarial value of a bronze plan is 60%. This means that 60% of medical costs are paid for by the insurance company, leaving the other 40% to be paid by you.
Silver Plan: The Silver plan is the second lowest cost plan, it has an actuarial value of 70%. This means that 70% of medical costs are paid for by the insurance company, leaving the other 30% to be paid by you. The Silver plan is the standard choice for most reasonably healthy families who historically use medical services.
Gold Plan: The Gold plan is the second most expensive plan, it has an actuarial value of 80%. This means that 80% of medical costs are paid for by the insurance company, leaving the other 20% to be paid by you.
Platinum Plan: The Platinum plan is the plan with the highest premiums offered on the insurance exchange. The Platinum plan as an actuarial value of 90%. This means that 90% of medical costs are paid for by the insurance company, leaving the other 10% to be paid by you. This plan is suggested to those with high incomes and those in poor health. Although coverage is more expensive up front the 90% coverage of costs will help those who use medical services frequently.
Catastrophic plans – which have very high deductibles and essentially provide protection from worst-case scenarios, like a serious accident or extended illness — are available to people under 30 years old and to people who have hardship exemptions from the fee that most people without health coverage must pay.
Iowa will expand its Medicaid program in 2014 to cover households with incomes up to 133% of the federal poverty level. That works out to about $15,800 a year for 1 person or $32,500 for a family of 4. You can find out whether you qualify for Medicaid in Iowa 2 ways: Contact your state Medicaid agency right now or fill out an application for coverage in the Health Insurance Marketplace.
Who can help you (the Navigators)
Genesis Health System will implement a navigator program through the Genesis Visiting Nurses Association (GVNA). Genesis plans to use existing relationships to aid residents and small business in accessing new sources of coverage.
The Visiting Nurse Services of Iowa will implement a navigator program serving 38 of Iowa’s 99 counties, home to approximately half of the uninsured in Iowa. The Visiting Nurse Services will provide navigator services through public awareness, education and assistance in enrolling individuals in qualified health plans. They also will partner with other organizations with considerable expertise in eligibility, enrollment, and knowledge of other health programs such as Medicaid and CHIP.
Planned Parenthood of the Heartland (PPHeartland) is a private, non-profit community-based health care agency operating in Arkansas, Iowa, Nebraska and Oklahoma. In Iowa, PPHeartland plans to have Navigators cover 61 counties and will strategically base Navigators in regions across Iowa.
If you need more detailed analysis, identification of issues, solutions, and implementation of your health insurance plan please let us know with the form below and we’ll get right back to you.
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Consumer Operated and Oriented Plan Program
Consumer Operated and Oriented Plan (CO-OP) Program are qualified nonprofit health insurance issuers that offer competitive health plans in the individual and small group markets. CO-OP in Iowa:
Accountable Care Organizations in Iowa
ACOs are profit-driven health innovators primarily serving Medicare patients who are financially rewarded by the government and private insurance companies for delivering medical services that lead to better health outcomes for less money.
- Sanford Health IA – Health Care Innovation Award
- University Of Iowa IA – Health Care Innovation Award
- Trustees Of Dartmouth College IA – Health Care Innovation Award
- State of Iowa IA – State Innovation Models Initiative: Model Design Award
Health care facilities where Innovation Models are being tested
- Jennie Edmundson Memorial Hospital Council Bluffs, IA – BPCI Initiative: Model 2
- Alegent Health Mercy Hospital Council Bluffs, IA – BPCI Initiative: Model 2
- Siouxland Care Transitions Sioux City, IA – Community-based Care Transition Program
- BEC Medical and Dental Des Moines, IA – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
- Community Health Centers of Southern Iowa, Inc. Lamoni, IA – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
- East Side Center Des Moines, IA – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
- Primary Health Center Marshalltown, IA – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
- Council Bluffs Community Health Center Council Bluffs, IA – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
- Kelly Taylor RN, MSN,CCM Des Moines, IA – Innovation Advisors Program
- Trinity Pioneer ACO Fort Dodge, IA – Pioneer ACO
The Insurance Exchange/Marketplace
What has been done, not been done, or left up to the federal government to do.
Establishing the Exchange in Iowa
On December 14, 2012, Governor Terry Branstad (R) informed federal officials that Iowa would pursue a state-federal partnership health insurance exchange.1 A state opting for a partnership exchange can choose to operate plan management functions, consumer assistance functions, or both. A state can also elect to perform Medicaid and Children’s Health Insurance Program (CHIP) eligibility determinations or use federal government services. Iowa will assume plan management functions in the Exchange and will continue to perform Medicaid and CHIP eligibility determinations. The state intends to transition to a fully state-based exchange in 2015.2
Prior to the decision to pursue a partnership exchange, the Iowa Department of Public Health, collaborating with the Insurance Division, the Department of Human Services, and the Department of Revenue, formed a Health Benefit Exchange Interagency Workgroup. In 2011, the Workgroup hosted a series of regional discussions with consumers, providers, insurance agents, business owners, and policy makers to gather public comments regarding the state’s development of an exchange and released a final report on the findings in June 2011.3 Workgroup representatives met with legislators and the Governor to provide updates on the exchange planning work being done in the state.4
Contracting with Plans: The Iowa Insurance Department (IID) will be responsible for Qualified Health Plan (QHP) certification and will use the System for Electronic Rate and Form Filing (SERFF) to facilitate the process. Issuers will use SERFF to submit QHP-specific rate and benefits data, which will be reviewed by IID to determine whether the QHP is compliant with certification standards. IID will then send its recommendations for final certification to the Center for Consumer Information and Insurance Oversight (CCIIO). IID intends to submit all QHP recommendations to CCIIO by June 21, 2013 and issuers will load QHP data into the federally-facilitated exchange (FFE) in July and August. IID will monitor plan management activities to ensure that QHPs meet quality and performance expectations and will partner with CCIIO to determine the best means of displaying QHP quality reporting to consumers. IID will also perform reviews of form and rate filings, network adequacy, and accreditation, licensure, and solvency standards. Iowa will not require plan standardization.5
Consumer Assistance and Outreach: In May 2012, Governor Branstad signed HF 2645 establishing licensing requirements and criteria for Navigators to be determined by the Insurance Commissioner.6,7 Iowa hired a subcontractor in November 2012 to examine design options for an Iowa Navigator Program and to develop a timeline for program implementation.8
Small Business Health Options Program (SHOP) Exchange: In November 2012, the state commissioned a report to review the statutory, regulatory, and administrative SHOP exchange requirements and to discuss major design and procurement decisions. The report recommends engaging stakeholders in the small group market as a next step towards developing a specific SHOP exchange design.9
Information Technology (IT): The Department does not believe Iowa’s current eligibility system can be modified to meet the requirements of the ACA and identified a significant need for IT investment.10 In September 2012, the Department hired a contractor to develop a new Medicaid and Children’s Health Insurance Program (CHIP) eligibility system that will have exchange interoperability. The initiative, called the Eligibility Integrated Application Solution (ELIAS) project, will provide real-time eligibility determinations for a number of public assistance programs and will eventually replace the current system.11 Iowa intends for ELIAS to interface with the federal data hub to acquire the necessary information for eligibility determination for Modified Adjusted Gross Income (MAGI) Medicaid/CHIP beneficiaries. ELIAS will also interface with the FFE by sending and receiving consumer account information; however this relationship will discontinue when Iowa transitions to a state-based Exchange. ELIAS is a Commercial Off-The-Shelf (COTS) system and is currently in the design phase.12
Essential Health Benefits (EHB): The ACA requires that all non-grandfathered individual and small-group plans sold in a state, including those offered through an exchange, cover certain defined health benefits. States must decide whether to benchmark their EHB plan to one of ten plans operating in the state or default to the largest small-group plan in the state. Since Iowa has not put forward a recommendation, the state’s benchmark EHB plan will default to the largest small-group plan in the state, Wellmark (Blue Cross Blue Shield)- Alliance Select, PPO.
Basic Health Program (BHP) Option: In November 2012, a subcontractor released a report that determined the BHP would cost the state additional funds unless fees equivalent to Medicaid reimbursement levels were paid to providers. The state awaits final rules from CMS for the BHP.13
In September 2010, the Iowa Department of Public Health received a federal Exchange Planning grant of $1 million. In November 2011, the Department received a federal Level One Establishment grant of $7.7 million to secure additional staff, identify and begin to establish systems and program capacity, build information technology infrastructure, and initiate a business and operational plan. Iowa received a second Level One Establishment grant for $26.6 million in August 2012, which it planned to use for further development of a new eligibility system. In January 2013, Iowa was awarded a third Level One grant for $6.8 million to develop a consumer assistance program.14
Expansion of Medicaid
From 2014 to 2017, the federal government will pay for 100% of the difference between a state’s current Medicaid eligibility level and the ACA minimum. Federal contributions to the expansion will drop to 95% in 2017 and remain at 90% after 2020, according to the ACA.
As the ACA was originally written, states would lose all Medicaid funding if they refused to expand their program to the ACA minimum.
However, the Supreme Court in June 2012 ruled that the federal government could not withhold Medicaid funding for states that chose not to expand their programs. The decision effectively allowed state officials to opt out of the expansion, and some have said they will do just that.
Iowa will enroll residents at or below 100% of the federal poverty level in Medicaid expansion.
On March 5, 2013, Iowa received conditional approval from the U.S. Department of Health and Human Services (HHS) to establish a partnership exchange. Final approval is contingent upon the state demonstrating its ability to perform all required Exchange activities on time, complying with future regulations, and achieving expected milestones.15
For more information on Iowa’s health insurance exchange planning visit: http://www.iid.state.ia.us/contact_us
1. Governor Branstad Letter to Secretary Sebelius. December 14, 2012.https://governor.iowa.gov/wp-content/uploads/2012/12/Governor-Branstad-letter-to-Secretary-Sebelius-FINAL.pdf
2. Iowa Department of Human Services. “Health Benefit Exchange (HBE).” January 9, 2013. Available at: http://www.dhs.state.ia.us/uploads/JVermeer%20Presentation%201-9-13v2.pdf
3. Iowa Health Benefit Exchange Regional Meeting and Focus Group Summary. June 2011.
4. Iowa 4th Quarterly report Planning Grant. October 15, 2011.http://www.idph.state.ia.us/hcr_committees/common/pdf/hbe/ia_quarter_4.pdf
5. Iowa Design Review Evidence: State Partnership Model, Section 4.0- Plan Management. November 14, 2012.
6. House File 2465. An Act Relating to State and Local Finances. May 18, 2012.http://coolice.legis.iowa.gov/Cool-ICE/default.asp?Category=billinfo&Service=Billbook&frame=1&GA=84&hbill=HF2465.
7. Governor Branstad. Approval and Transmission of House File 2465 (save Division VIII). May 25, 2012. https://www.legis.iowa.gov/docs/pubs/hjweb/pdf/May%2009,%202012.pdf#page=25.
8. Iowa’s Navigator Program: Background Research and Design Options. Health Management Associates. November 30, 2012. http://www.dhs.state.ia.us/uploads/CSG_4.pdf
9. Planning for the Small Business Health Options Program. CSG Government Solutions. November 30, 2012. http://www.dhs.state.ia.us/uploads/CSG_5.pdf
10. ‘Health Benefit Exchange 101: What are they and how do they work?’ May 30, 2012. Webinar Department of Public Health and Department of Human Services.http://www.idph.state.ia.us/hcr_committees/common/pdf/hbe/053012_slides.pdf
11. Iowa Medicaid Enterprise “Endeavors Update,” Iowa Department of Human Services. September 2012. Available at:http://www.dhs.state.ia.us/uploads/IME%20Newsletter%20Sept%202012.pdf
12. Iowa Design Review Evidence: State Partnership Model, Section 9.0- Technology. November 14, 2012.
13. State of Iowa, Department of Human Services, Iowa Medicaid Enterprise: Basic Health Program. Milliman. November 30, 2012. Available at:http://www.dhs.state.ia.us/uploads/Milliman_BasicHealthProgramBenchmark.pdf
14. Iowa Affordable Insurance Exchange Grant Awards List. Available at:http://cciio.cms.gov/archive/grants/states-exchanges/ia.html.
15. Letter from Secretary Sebelius to Governor Branstad. March 5, 2013. Available at:http://cciio.cms.gov/resources/files/ia-blueprint-letter-3-5-2013.pdf
Also of interest
Provided by the Henry J. Kaiser Family Foundation