Obamacare or ACA Simple Choice and Standardized Health Plans

New Jersey Obamacare

What Is a “Simple Choice” (Standardized) Health Plan?



What Is a “Simple Choice” (Standardized) Health Plan?

Standardized health plans offer a uniform set of features for each plan level – bronze, silver, and gold. For example, for 2017, all gold-level standardized plans will have a deductible of $1,250 but you can see your primary care doctor for $20 per visit at any time, even if you haven’t met your deductible.

In addition to deductibles and primary care visits, standardized components include:

  • out-of-pocket maximum
  • mental health visits
  • specialist visits
  • prescription drugs
  • urgent care
  • emergency room visits
  • inpatient hospitalization
  • lab work
  • x-rays and imaging
  • rehabilitative care, and
  • outpatient surgery.

As with primary care visits, you can obtain some of the services above—such as mental health visits and at least some prescription drugs—for a set copay amount without having to meet your deductible. To see specifics for bronze, silver, and gold plans offered at HealthCare.gov, see

To chart below sets out specifics for the bronze, silver, and gold plans to be offered on HealthCare.gov for 2017. (You can find more details in 2017 Standardized Options, a document available on the website of the Centers for Medicare Medicaid Services (CMS).)

 

2017 Standardized OpionsBronzeSilverSilver 73% Actuarial Value VariationSilver 87% Actuarial Value VariationSilver 94% Actuarial Value VariationGold
Actuarial Value (%) 61.88 70.63 73.55 87.47 94.30 79.98
Deductible $6,650 $3,500 $3,000 $700 $250 $1,250
Annual Limitation on Cost Sharing $7,150 $7,150 $5,700 $2,000 $1,250 $4,750
Emergency Room Service 50% $400 (copay applies only after deductible $300 (copay applies only after deductible $150 (copay applies only after deductible) $100 (copay applies only after deductible) $250 (copay applies only after deductible)
Urgent Care 50% $75 (*) $75 (*) $40 (*) $25 (*) $65 (*)
inpaitient Hospital Services 50% 20% 20% 20% 5% 20%
Primary Care Visit $45 (* first 3 visits, then subject to deductible and 50% coinsurance) $30 (*) $30 (*) $10 (*) 5% (*) $20 (*)
Specialist Visit 50% $65 (*) $65 (*) $25 (*) $15 (*) $50 (*)
Mental Health/ Substance Use Disorder Outpatient Services $45 (*) $30 (*) $30 (*) $10 (*) $5 (*) $20 (*)
Imaging (CT/PET Scans, MRIs) 50% 20% 20% 20% 5% 20%
Rehabilitative Speech Therapy 50% 20% 20% 20% 5% 20%
Rehabilitative OT/PT 50% 20% 20% 20% 5% 20%
Laboratory Services 50% 20% 20% 20% 5% 20%
X-rays 50% 20% 20% 20% 5% 20%
Skilled Nursing Facility 50% 20% 20% 20% 5% 20%
Outpatient Facility Fee 50% 20% 20% 20% 5% 20%
Outpatient Surgery Physician/Surgical 50% 20% 20% 20% 5% 20%
Generic Drugs $35 (*) $15 (*) $10 (*) $5 (*) $3 (*) $10 (*)
Preferred Brand Drugs 35% $50 (*) $50 (*) $25 (*) $5 (*) $30 (*)
Non-Preferred Brand Drugs 40% $100 (*) $100 (*) $50 (*) $10 (*) $75 (*)
Specialty Drugs 45% 40% 40% 30% 25% 30%

 

You may have noticed that one thing absent from the list of standardized components is the monthly premium cost. Premiums for standardized plans vary, so you will want to compare carefully before choosing one. The good news is that standardized plans are easier to compare because there are fewer variations among them. Also, they may bring basic health care services within easier reach by allowing copays for some types of care regardless of the deductible.

Beginning with open enrollment for 2017, HealthCare.gov will be offering standardized plans under the label “Simple Choice.” Many states operating their own exchanges offer standardized plans as well, though they are not the norm in most states (Covered California is a notable exception, offering only standardized plans) and insurers aren’t required to provide them.

You’ll be able to see the full range of health plan choices available to you when you visit the exchange for New Jersey (HealthCare.gov) during open enrollment, between November 1, 2016 and January 31, 2017. A broker can also help you assess your alternatives for care; you can talk directly with a broker by calling 1-800-943-6832.

As we enter the fourth Affordable Care Act open enrollment season facing sharply increased costs and fewer choices, Simple Choice or standardized health plans may turn out to be a good option for many.


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