Please read this before making your decision

Should you Apply to a Covered California Exchange health plan now, or wait until the Off Exchange health plans are released (late Nov.)?

What you need to consider in your decision:

A) Do you qualify for a Tax Subsidy?
You may estimate your health plan premiums and subsidies using the Shop and Compare Tool Calculator on the Covered California website.

https://www.coveredca.com/shopandcompare/#calculator

If you know that you do qualify for a subsidy, and want to take advantage of it, then you should apply to Covered CA, naming us as your Designated Agent (Instructions on Agent Designation are attached).

If you know that you do not qualify for a subsidy, it will be to your advantage to consider plans that are outside of the Covered CA Exchange. Plans sold in the Exchange are also available outside of the Exchange at the same prices with the same benefits. There will be a larger number of plans to choose from outside. The plans outside the Exchange may have different provider networks.

In addition, applications to plans outside the Exchange will not require you to divulge personal information like income and immigration status to Govt. entities like the IRS, CMS, HHS, NSA, Homeland Security, etc.

B) Are your doctors and hospitals listed in the Provider Network of the plan that you are considering?
Most Individual/Family plans, whether in or out of the Covered CA Exchange, will have reduced or “skinny” provider networks. These plans do not have the same full PPO or HMO networks that you may have been used to with pre-ACA plans. The provider search function in coveredca.com may not have up to date listings. However several of the carriers have posted “provider finders” on their own websites. Please be aware that physicians are still negotiating with the carriers, and that these networks may change daily.

Anthem Blue Cross has notified us that they will only be offering a limited, reduced size provider network for their Individual/Family plans in and out of the Covered CA Exchange.
Blue Shield of CA has notified us that they will be offering a limited provider network for all their Individual/Family metallic plans in and out of the Covered CA Exchange. The new network will have 50% of the doctors and 70% of the hospitals of their previous full network.
Kaiser has notified us that their network will be the same in and out of the Exchange, and same as their current network.
Health Net has not yet announced their decision on provider networks.

If you are not able to find a satisfactory provider network among the Individual and Family plans inside or outside of the Exchange, Please give us a call at 925-284-2000. There may be small business group plans with wider networks — as long as you have a business with 2 or more employees.

To search for Doctors and Hospitals:
Anthem Blue Cross Provider Finder:
http://www.anthem.com/wps/portal/ca/popcontent?content_path=shared/f1/s0/t0/pw_e206382.htm

Blue Shield of CA Provider Finder:
https://www.blueshieldca.com/fap/app/search.html

C) Are your prescription drugs on the Drug Formulary List of the plan that you are applying to?
Please be aware that carriers have told us that they may be modifying and likely reducing some of their prescription drug formulary lists prior to Jan. 1.
Some carriers are starting to post their formulary lists on their websites. But those lists may be updates frequently.

For your convenience, I have attached a link to the online formulary lists for Anthem Blue Cross and Blue Shield. Please keep in mind that these lists may change.

Anthem Blue Cross Drug Formulary list can be found at:
http://www.anthem.com/ca/CAExchangedruglist4.pdf

Blue Shield Formulary List can be found at:
https://www.blueshieldca.com/bsca/documents/pharmacy/Standard_Formulary.pdf

D) Are you on a grandfathered health plan?
If you are on a grandfathered plan, you will have received a letter from your carrier notifying you of that.
If you do not know, you need to call your carrier to find out.
If you do have a grandfathered plan, that health plan will retain your existing provider network, drug formulary list and benefit design.
If you find that the new ACA-compliant plans for 2014 do not satisfy the provider network, formulary list or prices that you want, then you may keep this grandfathered plan.

To recap, apply now to Covered CA (with us as your Designated Agent) if you are certain that:
1. You qualify for a Tax Subsidy
2. Your doctors and hospitals are in the plan’s reduced network.
3. Your prescription drugs are in the plan’s Formulary List and you do not need to obtain prior authorization from the new Exchange plan to continue an expensive prescription medication.
4. You do not want to consider any of the non-Exchange health plans. (You have to wait until Nov. 15 or later for details on these outside plans.)
5. You do not want to keep a grandfathered plan which may have a more favorable provider network or drug formulary list.
6. You are comfortable with the fact that Covered CA will be sharing your PII (Personal Identifiable Information), PHI (Private Health Information) and financial information with other government and non-government entities that may include the IRS, Dept. of Homeland Security, Center for Medicare Medicaid Services, US Dept. of Health & Human Services, Dept. of Labor, Dept. of Insurance, Dept. of Managed Health Care, the State of California and Equifax.
7. You are comfortable that the Covered CA website will provide adequate security and protection against hacking and identity theft.

If you are not comfortable with the incomplete information right now, I would recommend waiting until after Nov. 15 when more is known.

Documents or information you may need to make your decision and apply for coverage?
• Your W-2 wage statement
• Your IRS 1040 form showing your household AGI income
• Your current health plan information such as ID card, plan summary, billing statement, cancellation notice, notice of mapping, premium increase letter, letter of grandfathered status, etc.
• Drivers License, Passport, Resident Alien ID card or naturalization papers.

Caution:
We are informed by the insurance carriers that the Provider Network lists and the Prescription Drug Formulary lists posted online have not been finalized, and that there may be changes to these lists.
Please be aware that if you qualify for a federal subsidy to help pay the premium, this subsidy may change at any time should your income change or should the laws change.
Please be aware that an application to the Covered CA Exchange requires you to submit sensitive PII (Personal Identifiable Information) and PHI (Private Health Information) to a Government entity which may share this info with several other Govt. and non-government entities that may include the IRS, Dept. of Homeland Security, Center for Medicare Medicaid Services, US Dept. of Health & Human Services, Dept. of Labor, the Dept. of Insurance, Dept. of Managed Health Care, the State of California and Equifax.
There may be other, as yet undiscovered, risks related to your application to Covered California.

Philip W Lee
www.health-insurance.com
www.healthplantalk.com

Decision Time For Small Employer Groups (50 or fewer employees)
If you have an existing Small Group Plan, the following are some possible options that you may need to decide:
• Do nothing. Allow your plan to renew at the regularly scheduled renewal date in 2014. At that time, all ACA regulations and prices will be imposed. (An exception would be grandfathered plans prior to 3/23/2010).
• Renew early on Dec. 1st. Take advantage of carriers’ promotional RAF’s. Lock in rates and plans for 12 months. Delay impact of most of ACA-imposed regulations.
• Use Dec. 1st Early Renewal to change plans and lock in rates for 12 months.
• Use Dec.1st carrier RAF promotions to change to a more favorable rate or plan at another carrier.
• Renew on Jan. 1st to change to an ACA-compliant plan, and accept new rules on probation and family ratings.
• Change to another carrier on Jan. 1st or later (even after you have early renewed on Dec. 1st).
• Ask your Tax Advisor to help you calculate if your company may qualify for a Tax Credit. If so, you may want to consider buying an Exchange and ACA-compliant plan on Jan. 1st.

These decisions are complicated. Circumstances vary and every company’s options are different. You should consult with a certified insurance agent before making a decision.
Decision Time For Individuals and Families
If you already have an existing individual health plan. You may have to decide on one of these possible options. The following example is based on someone on an Anthem Blue Cross plan:
5. Do nothing. Allow Anthem to map your current plan to a comparable 2014 ACA-compliant plan on Jan. 1st. You will still have the opportunity, until March 31, to change to any other plan, inside or outside the Exchange.
6. If you have a grandfathered plan (prior to March 23, 2010), you may keep your plan and remain unchanged, except for the rate.
7. Use Anthem’s calculator tools online to compare plans and decide whether to change plans or not, and if so, whether to move to an Exchange or Non-Exchange plan.
8. Use the Covered CA Exchange’s coveredca.com online subsidy calculator to estimate if you and your family may qualify for a subsidy. If so, you may want to consider applying for an Exchange plan for Jan. 1. (Please keep in mind that if you apply for a subsidy, you will be required to disclose financial, personal and tax return info, which will be verified by different Govt. entities.)

These decisions are complicated. Circumstances vary and every individual’s options are different. You should consult with a certified insurance agent before making a decision.

Tips
• Anthem will be providing online decision tools: www.healthcareform4you.com, www.changemycoverage.com.
• The Exchange’s Covered California website will provide calculator tools for estimating if you might be eligible for a subsidy. www.coveredca.com.
• Your certified insurance agent will have powerful online Quote Engine tools to help you compare all plans in the marketplace, both inside and outside the Covered CA Exchange.
• Please remember that everyone’s personal situation is different. What may be the right move for a friend or family member may not be the right move for you. You have to tailor the decision to your own circumstances.

Key dates to remember:
• 10/1/2013 — Carriers release their 2014 Rates and Plans, for plans inside as well as outside the Covered California Exchange.
• 1/1/2014 — Implementation of the ACA (or Obamacare). All plans sold with this effective date or later must be ACA-compliant.
• 10/1/2013 – 3/31/2014 — Open Enrollment Period for all Individual and Family plans.
• 3/31/2014 — Last effective date to enroll into an Individual/Family plan without a special qualifying event.
• 10/15/2014 – 12/6/2014 — Open Enrollment Period for 1/1/2015 plans.

Phil Lee
800-286-7445
www.Health-Insurance.com
www.HealthPlanTalk.com