Learn how to effectively and efficiently help consumers through the plan selection process and how to breakdown some of the difficult health insurance concepts when working with the remaining uninsured and newly enrolled.

1. © 2015 Enroll America and Get Covered America
EnrollAmerica.org | GetCoveredAmerica.org
Dave Chandra, Senior Policy Analyst, Center on Budget and Policy Priorities | 06.11.15
How to Effectively and Efficiently
Help Consumers Navigate Plan
Selection

2. 1. Trends in Marketplace QHPs
2. Analyzing QHPs in your Region
3. Assisting Consumers in Plan Selection - Demonstration
4. Assisting Consumers in Plan Selection - Interactive
exercise
2
Presentation Overview

3. Trends in Marketplace QHPs

4. Overview of Marketplace Health Plan Elements
1. Premium
2. Cost Sharing
– Deductible
– Co-pays/Co-insurance
– Out-of-Pocket Maximum
3. Benefits/Drug Formulary
4. Provider Network
4

5. Copays
Fixed
dollar
amount
per
visit
or
per
day
paid
by
the
enrollee.
Coinsurance
Percent
of
a
medical
fee/bill
paid
by
the
enrollee
Copays and Coinsurance
Overview
Source:
HealthCare.gov,
Kaiser
Permanente
KP
VA
0/20/Dental
and
KP
VA
1000/20/Dental
Gold
Plans
for
Fairfax
County,
VA
5

6. Increase of Coinsurance in QHPs
6
Source:
HealthCare.gov,
Highmark
Health
Savings
Blue
PPO
2750
Silver
plan
for
Westmoreland
County,
PA

7. Copays and Coinsurance
Prescription Drug Copay Tiers
7
Source:
HealthCare.gov,
UPMC
Advantage
Value
Silver
Select
plan
for
Westmoreland
County,
PA

8. Additional Tiering of Prescription Drug Copays
8
Source:
Summary
of
Benefits
and
Coverage
for
Humana
Silver
4600/AusRn
HMOx
in
Travis
County,
TX

9. Additional Tiering of Prescription Drug Copays
9
SourceHumana
Silver
4600/AusRn
HMOx
in
Travis
County,
TX

10. Services/Copays Exempt from the Deductible
10
Source:
HealthCare.gov,
Anthem
HealthKeepers
Silver
X
3350
15
plan
for
Fairfax
County,
VA
deduc%ble
applies

11. Services/Copays Exempt from the Deductible
11
Source:
HealthCare.gov,
Anthem
HealthKeepers
Silver
X
3350
15
plan
for
Fairfax
County,
VA
deduc%ble
does
not
apply

12. HSA vs. Non-HSA Plans
12
Source:
HealthCare.gov,
Kaiser
Permanente
Bronze
4500/5-­‐/HAS/Dental/Ped
Dental
and
Bronze
4500/5-­‐/Dental/Ped
Dental
plans
in
Fairfax
County
VA

13. “3 Step Copay”(Copay/Deductible/Coinsurance)
13
Source:
Summary
of
Benefits
and
Coverage
for
Anthem
HealthKeepers
Bronze
X
4500
35
in
Fairfax
County,
VA

14. “3 Step Copay”(Copay/Deductible/Coinsurance)
14
Source:
HealthCare.gov,
Anthem
HealthKeepers
Bronze
X
4500
35
in
Fairfax
County,
VA

15. Cost Sharing Reduction (CSR) Plans
15
FPL%
Silver
Plan
Eligibility
<
150%
94%
variant
151%
-­‐
200%
87%
variant
201%
-­‐
250%
73%
variant
>
251%
70%
base
plan

16. Cost Sharing Reduction (CSR) Plans
16

17. Cost Sharing Reduction (CSR) Plans
17

18. Essential Health Benefits
18

19. Pediatric Dental Benefit
Source:
healthcare.gov,
InnovaRon
Health-­‐Aetna
INOVA
Silver
$10
Copay
plan
and
Kaiser
Permanente
VA
Silver
1750/25%/HSA/Dental/Ped
Dental
plan
for
Fairfax
County,
VA
19

20. Essential Health Benefits
Other Covered Services
20
Source:
Summary
of
Benefits
and
Coverage
for
New
Mexico
Health
ConnecRons
Healthy
Connect
Bronze
HMO
in
Albuquerque,
NM

21. 21
Type
Name
PCP
Required?
Referrals
Required?
Out-­‐of-­‐
Network
Coverage?
PPO
Preferred
Provider
Organiza%on
No
No
Yes
POS
Point
of
Service
Yes
Maybe
Yes
HMO
Health
Maintenance
Organiza%on
Yes
Yes
No*
EPO
Exclusive
Provider
Organiza%on
No
No
No*
*except
for
emergency
care
Health Plan Network Types

22. QHPs with Narrow Provider Networks
Health plans are using narrow provider networks to keep costs down
22

23. QHPs with Tiered Networks
23
Source:
Plan
Brochure
for
Independence
Blue
Cross
HMO
Silver
ProacRve
Plan
in
Philadelphia
County,
PA

24. Tiered Provider Networks
24
Source:
Summary
of
Benefits
and
Coverage
for
Independence
Blue
Cross
HMO
Silver
ProacRve
Plan
in
Philadelphia
County,
PA

25. Confusion and Inaccuracies in Provider Directories
25
Source:
HealthCare.gov
and
Provider
Search
site
for
BlueCross
BlueShield
BlueCare
SoluRons
Plan
in
Sedgwick
County,
KS

26. Preparing for Open Enrollment III
Analyzing QHPs in your Region

27. Comparing 2014 and 2015 Marketplace Plans
27
Source:
ProPublica,
h`p://projects.propublica.org/aca-­‐enrollment/#

28. Comparing 2014 and 2015 Marketplace Plans
28
Source:
ProPublica,
h`p://projects.propublica.org/aca-­‐enrollment/#

29. Analyzing Changes to QHPs in Your Region
29

30. Comparing QHPs in Your Region
30

31. Comparing QHPs in Your Region – Additional Benefits
31
Service
CareFirst
BCBS
Innova%on
Health
Kaiser
Permanente
Acupuncture
Bariatric
Surgery
X
X
ChiropracCc
Care
X
X
X
CosmeCc
Surgery
Coverage
Outside
the
U.S.
X
Dental
Care
for
Adults
X
Dental
Care
for
Children
X
Hearing
Aids
Hearing
Aids
InferClity
Treatment
X
Long-­‐Term/Custodial
Nursing
Home
Care
Non-­‐Emergency
Care
when
Traveling
Outside
the
US
X
Private-­‐Duty
Nursing
X
X
X
Eye
Care
for
Adults
X
X
RouCne
Foot
Care
RouCne
Hearing
Tests
X
Weight
Loss
Programs

32. Demonstration
Assisting Consumers in
Plan Selection

33. CBPP Marketplace Plan Comparison Worksheet
available
at:
hQp://
www.healthreformbeyondthebasics.org/
marketplace-­‐plan-­‐comparison-­‐worksheet/
33

34. Scenario 1: James and Ann (married couple)
34
James
Ann
Age
52
45
County
Oakland
County,
MI
Zip
Code
48324
Income
$0
$23,000
Federal
Poverty
Level
144%
Employer
coverage?
no
no
Insurance
status
uninsured
uninsured

35. Scenario 1: James and Ann (married couple)
35

36. Scenario 1: James and Ann (married couple)
36

37. Scenario 1: James and Ann (married couple)
37

38. Scenario 1: James and Ann (married couple)
38
Applicant
Name:
Tax
Credit
(monthly):
Date:
Number
of
people
in
the
plan:
Eligible
for
cost-­‐sharing
reducCons?
□
No
□
73%
□
87%
□
94%
Marketplace
Plan
Comparison
Worksheet
Option 1 Option 2 Option 3
Insurance company
Health plan name
Metal tier (Bronze, Silver, Gold, Platinum)
Plan type (HMO, PPO, POS, EPO, or other)
Monthly premium (after tax credit)

39. Scenario 1: James and Ann (married couple)
39
Applicant
Name:
James and Ann Tax
Credit
(monthly):
$549.66
Date:
6/11/15
Number
of
people
in
the
plan:
2 Eligible
for
cost-­‐sharing
reducCons?
□
No
□
73%
□
87%
ý
94%
Marketplace
Plan
Comparison
Worksheet
Option 1 Option 2 Option 3
Insurance company
Health plan name
Metal tier (Bronze, Silver, Gold, Platinum)
Plan type (HMO, PPO, POS, EPO, or other)
Monthly premium (after tax credit)

40. 40
Copays/Coinsurance Amount Amount Amount
Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes)
Primary Care Provider (PCP) visit
Specialist visit
Prescriptions
Generic drugs
Preferred brand name drugs
Non-preferred brand name drugs
Specialty drugs
Emergency Room (ER) visit
Inpatient hospital stay
Other service:
Other service:
Option 1 Option 2 Option 3
Insurance company
Health plan name
Plan type (HMO, PPO, POS, EPO, or other)
Monthly premium (after tax credit)
Deductible (medical/drug or combined)
Out-of-Pocket Maximum (OOP Max)
Health Care Providers In Network/Covered? In Network/Covered? In Network/Covered?
Current doctor/provider:
Other provider or hospital:
Current prescription drugs:
Scenario 1: James and Ann (married couple)

41. 41
Copays/Coinsurance Amount Amount Amount
Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes)
Primary Care Provider (PCP) visit
Specialist visit
Prescriptions
Generic drugs
Preferred brand name drugs
Non-preferred brand name drugs
Specialty drugs
Emergency Room (ER) visit
Inpatient hospital stay
Other service: Laboratory Services
Other service: X-rays and Diagnostic Imaging
Option 1 Option 2 Option 3
Insurance company
Health plan name
Plan type (HMO, PPO, POS, EPO, or other)
Monthly premium (after tax credit)
Deductible (medical/drug or combined)
Out-of-Pocket Maximum (OOP Max)
Health Care Providers In Network/Covered? In Network/Covered? In Network/Covered?
Current doctor/provider:
Other provider or hospital:
Current prescription drugs:
Scenario 1: James and Ann (married couple)

42. Scenario 1: James and Ann (married couple)

43. Scenario 1: James and Ann (married couple)

44. 44
Scenario 1: James and Ann (married couple)

45. 45
Scenario 1: James and Ann (married couple)

46. 46
Scenario 1: James and Ann (married couple)

47. 47
Copays/Coinsurance Amount Amount Amount
Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes)
Primary Care Provider (PCP) visit
Specialist visit
Prescriptions
Generic drugs
Preferred brand name drugs
Non-preferred brand name drugs
Specialty drugs
Emergency Room (ER) visit
Inpatient hospital stay
Other service: Laboratory Services
Other service: X-rays and Diagnostic Imaging
Option 1 Option 2 Option 3
Insurance company
Health plan name
Plan type (HMO, PPO, POS, EPO, or other)
Monthly premium (after tax credit)
Deductible (medical/drug or combined)
Out-of-Pocket Maximum (OOP Max)
Health Care Providers In Network/Covered? In Network/Covered? In Network/Covered?
Current doctor/provider:
Other provider or hospital:
Current prescription drugs:
Scenario 1: James and Ann (married couple)

48. 48
Copays/Coinsurance Amount Amount Amount
Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes)
Primary Care Provider (PCP) visit
Specialist visit
Prescriptions
Generic drugs
Preferred brand name drugs
Non-preferred brand name drugs
Specialty drugs
Emergency Room (ER) visit
Inpatient hospital stay
Other service: Laboratory Services
Other service: X-rays and Diagnostic Imaging
Option 1 Option 2 Option 3
Insurance company Humana
Health plan name Silver 4600/Detroit HMOx
Plan type (HMO, PPO, POS, EPO, or other) HMO
Monthly premium (after tax credit) $36
Deductible (medical/drug or combined) $1,000 (combined)
Out-of-Pocket Maximum (OOP Max) $1,500
Health Care Providers In Network/Covered? In Network/Covered? In Network/Covered?
Current doctor/provider:
Other provider or hospital:
Current prescription drugs:
Scenario 1: James and Ann (married couple)

49. 49
Copays/Coinsurance Amount Amount Amount
Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes)
Primary Care Provider (PCP) visit $25
Specialist visit $35
Prescriptions
Generic drugs $17*
Preferred brand name drugs $50 ü
Non-preferred brand name drugs 50% ü
Specialty drugs 50% ü
Emergency Room (ER) visit 20% ü
Inpatient hospital stay 20% ü
Other service: Laboratory Services 20% ü
Other service: X-rays and Diagnostic Imaging 20% ü
Option 1 Option 2 Option 3
Insurance company Humana
Health plan name Silver 4600/Detroit HMOx
Plan type (HMO, PPO, POS, EPO, or other) HMO
Monthly premium (after tax credit) $36
Deductible (medical/drug or combined) $1,000 (combined)
Out-of-Pocket Maximum (OOP Max) $1,500
Health Care Providers In Network/Covered? In Network/Covered? In Network/Covered?
Current doctor/provider:
Other provider or hospital:
Current prescription drugs:
Scenario 1: James and Ann (married couple)

50. 50
Copays/Coinsurance Amount Amount Amount
Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes)
Primary Care Provider (PCP) visit $25 $10
Specialist visit $35 $30 ü
Prescriptions
Generic drugs $17* 1A - $4, 1B - $20
Preferred brand name drugs $50 ü 25% ü
Non-preferred brand name drugs 50% ü 50% ü
Specialty drugs 50% ü 20% ü
Emergency Room (ER) visit 20% ü $100/10% ü
Inpatient hospital stay 20% ü 10% ü
Other service: Laboratory Services 20% ü no charge ü
Other service: X-rays and Diagnostic Imaging 20% ü 10% ü
Option 1 Option 2 Option 3
Insurance company Humana Blue Care Network of MI
Health plan name Silver 4600/Detroit HMOx Metro Detroit HMO Silver
Plan type (HMO, PPO, POS, EPO, or other) HMO HMO
Monthly premium (after tax credit) $36 $73
Deductible (medical/drug or combined) $1,000 (combined) $350 (combined)
Out-of-Pocket Maximum (OOP Max) $1,500 $1,000
Health Care Providers In Network/Covered? In Network/Covered? In Network/Covered?
Current doctor/provider:
Other provider or hospital:
Current prescription drugs:
Scenario 1: James and Ann (married couple)

51. 51
Copays/Coinsurance Amount Amount Amount
Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes)
Primary Care Provider (PCP) visit $25 $10 $10 n/a
Specialist visit $35 $30 ü $20 n/a
Prescriptions
Generic drugs $17* 1A - $4, 1B - $20 no charge n/a
Preferred brand name drugs $50 ü 25% ü $15 n/a
Non-preferred brand name drugs 50% ü 50% ü $50 n/a
Specialty drugs 50% ü 20% ü $50 n/a
Emergency Room (ER) visit 20% ü $100/10% ü $75 n/a
Inpatient hospital stay 20% ü 10% ü no charge n/a
Other service: Laboratory Services 20% ü no charge ü no charge n/a
Other service: X-rays and Diagnostic Imaging 20% ü 10% ü $20 n/a
Option 1 Option 2 Option 3
Insurance company Humana Blue Care Network of MI Total Health Care USA
Health plan name Silver 4600/Detroit HMOx Metro Detroit HMO Silver Totally You (Silver)
Plan type (HMO, PPO, POS, EPO, or other) HMO HMO HMO
Monthly premium (after tax credit) $36 $73 $96
Deductible (medical/drug or combined) $1,000 (combined) $350 (combined) $0
Out-of-Pocket Maximum (OOP Max) $1,500 $1,000 $1,500
Health Care Providers In Network/Covered? In Network/Covered? In Network/Covered?
Current doctor/provider:
Other provider or hospital:
Current prescription drugs:
Scenario 1: James and Ann (married couple)

52. 52
Copays/Coinsurance Amount Amount Amount
Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes)
Primary Care Provider (PCP) visit $25 $10 $10 n/a
Specialist visit $35 $30 ü $20 n/a
Prescriptions
Generic drugs $17* 1A - $4, 1B - $20 no charge n/a
Preferred brand name drugs $50 ü 25% ü $15 n/a
Non-preferred brand name drugs 50% ü 50% ü $50 n/a
Specialty drugs 50% ü 20% ü $50 n/a
Emergency Room (ER) visit 20% ü $100/10% ü $75 n/a
Inpatient hospital stay 20% ü 10% ü no charge n/a
Other service: Laboratory Services 20% ü no charge ü no charge n/a
Other service: X-rays and Diagnostic Imaging 20% ü 10% ü $20 n/a
Option 1 Option 2 Option 3
Insurance company Humana Blue Care Network of MI Total Health Care USA
Health plan name Silver 4600/Detroit HMOx Metro Detroit HMO Silver Totally You (Silver)
Plan type (HMO, PPO, POS, EPO, or other) HMO HMO HMO
Monthly premium (after tax credit) $36 $73 $96
Deductible (medical/drug or combined) $1,000 (combined) $350 (combined) $0
Out-of-Pocket Maximum (OOP Max) $1,500 $1,000 $1,500
Health Care Providers In Network/Covered? In Network/Covered? In Network/Covered?
Current doctor/provider: D. Willens, MD
Other provider or hospital:
Current prescription drugs:
Scenario 1: James and Ann (married couple)

53. 53
Copays/Coinsurance Amount Amount Amount
Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes)
Primary Care Provider (PCP) visit $25 $10 $10 n/a
Specialist visit $35 $30 ü $20 n/a
Prescriptions
Generic drugs $17* 1A - $4, 1B - $20 no charge n/a
Preferred brand name drugs $50 ü 25% ü $15 n/a
Non-preferred brand name drugs 50% ü 50% ü $50 n/a
Specialty drugs 50% ü 20% ü $50 n/a
Emergency Room (ER) visit 20% ü $100/10% ü $75 n/a
Inpatient hospital stay 20% ü 10% ü no charge n/a
Other service: Laboratory Services 20% ü no charge ü no charge n/a
Other service: X-rays and Diagnostic Imaging 20% ü 10% ü $20 n/a
Option 1 Option 2 Option 3
Insurance company Humana Blue Care Network of MI Total Health Care USA
Health plan name Silver 4600/Detroit HMOx Metro Detroit HMO Silver Totally You (Silver)
Plan type (HMO, PPO, POS, EPO, or other) HMO HMO HMO
Monthly premium (after tax credit) $36 $73 $96
Deductible (medical/drug or combined) $1,000 (combined) $350 (combined) $0
Out-of-Pocket Maximum (OOP Max) $1,500 $1,000 $1,500
Health Care Providers In Network/Covered? In Network/Covered? In Network/Covered?
Current doctor/provider: D. Willens, MD
Other provider or hospital: # of oncologists
Current prescription drugs:
Scenario 1: James and Ann (married couple)

54. 54
Copays/Coinsurance Amount Amount Amount
Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes)
Primary Care Provider (PCP) visit $25 $10 $10 n/a
Specialist visit $35 $30 ü $20 n/a
Prescriptions
Generic drugs $17* 1A - $4, 1B - $20 no charge n/a
Preferred brand name drugs $50 ü 25% ü $15 n/a
Non-preferred brand name drugs 50% ü 50% ü $50 n/a
Specialty drugs 50% ü 20% ü $50 n/a
Emergency Room (ER) visit 20% ü $100/10% ü $75 n/a
Inpatient hospital stay 20% ü 10% ü no charge n/a
Other service: Laboratory Services 20% ü no charge ü no charge n/a
Other service: X-rays and Diagnostic Imaging 20% ü 10% ü $20 n/a
Option 1 Option 2 Option 3
Insurance company Humana Blue Care Network of MI Total Health Care USA
Health plan name Silver 4600/Detroit HMOx Metro Detroit HMO Silver Totally You (Silver)
Plan type (HMO, PPO, POS, EPO, or other) HMO HMO HMO
Monthly premium (after tax credit) $36 $73 $96
Deductible (medical/drug or combined) $1,000 (combined) $350 (combined) $0
Out-of-Pocket Maximum (OOP Max) $1,500 $1,000 $1,500
Health Care Providers In Network/Covered? In Network/Covered? In Network/Covered?
Current doctor/provider: D. Willens, MD
Other provider or hospital: # of oncologists
Current prescription drugs: metformin
Scenario 1: James and Ann (married couple)

55. 55
Scenario 1: James and Ann (married couple)

56. 56
Scenario 1: James and Ann (married couple)

57. 57
Scenario 1: James and Ann (married couple)

58. 58
Scenario 1: James and Ann (married couple)

59. 59
Scenario 1: James and Ann (married couple)

60. 60
Scenario 1: James and Ann (married couple)

61. 61
Scenario 1: James and Ann (married couple)

62. 62
Copays/Coinsurance Amount Amount Amount
Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes)
Primary Care Provider (PCP) visit $25 $10 $10 n/a
Specialist visit $35 $30 ü $20 n/a
Prescriptions
Generic drugs $17* 1A - $4, 1B - $20 no charge n/a
Preferred brand name drugs $50 ü 25% ü $15 n/a
Non-preferred brand name drugs 50% ü 50% ü $50 n/a
Specialty drugs 50% ü 20% ü $50 n/a
Emergency Room (ER) visit 20% ü $100/10% ü $75 n/a
Inpatient hospital stay 20% ü 10% ü no charge n/a
Other service: Laboratory Services 20% ü no charge ü no charge n/a
Other service: X-rays and Diagnostic Imaging 20% ü 10% ü $20 n/a
Option 1 Option 2 Option 3
Insurance company Humana Blue Care Network of MI Total Health Care USA
Health plan name Silver 4600/Detroit HMOx Metro Detroit HMO Silver Totally You (Silver)
Plan type (HMO, PPO, POS, EPO, or other) HMO HMO HMO
Monthly premium (after tax credit) $36 $73 $96
Deductible (medical/drug or combined) $1,000 (combined) $350 (combined) $0
Out-of-Pocket Maximum (OOP Max) $1,500 $1,000 $1,500
Health Care Providers In Network/Covered? In Network/Covered? In Network/Covered?
Current doctor/provider: D. Willens, MD
Other provider or hospital: # of oncologists
Current prescription drugs: metformin
Scenario 1: James and Ann (married couple)

63. 63
Copays/Coinsurance Amount Amount Amount
Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes)
Primary Care Provider (PCP) visit $25 $10 $10 n/a
Specialist visit $35 $30 ü $20 n/a
Prescriptions
Generic drugs $17* 1A - $4, 1B - $20 no charge n/a
Preferred brand name drugs $50 ü 25% ü $15 n/a
Non-preferred brand name drugs 50% ü 50% ü $50 n/a
Specialty drugs 50% ü 20% ü $50 n/a
Emergency Room (ER) visit 20% ü $100/10% ü $75 n/a
Inpatient hospital stay 20% ü 10% ü no charge n/a
Other service: Laboratory Services 20% ü no charge ü no charge n/a
Other service: X-rays and Diagnostic Imaging 20% ü 10% ü $20 n/a
Option 1 Option 2 Option 3
Insurance company Humana Blue Care Network of MI Total Health Care USA
Health plan name Silver 4600/Detroit HMOx Metro Detroit HMO Silver Totally You (Silver)
Plan type (HMO, PPO, POS, EPO, or other) HMO HMO HMO
Monthly premium (after tax credit) $36 $73 $96
Deductible (medical/drug or combined) $1,000 (combined) $350 (combined) $0
Out-of-Pocket Maximum (OOP Max) $1,500 $1,000 $1,500
Health Care Providers In Network/Covered? In Network/Covered? In Network/Covered?
Current doctor/provider: D. Willens, MD û û û
Other provider or hospital: # of oncologists
Current prescription drugs: metformin
Scenario 1: James and Ann (married couple)

64. 64
Scenario 1: James and Ann (married couple)

65. 65
Scenario 1: James and Ann (married couple)

66. 66
Copays/Coinsurance Amount Amount Amount
Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes)
Primary Care Provider (PCP) visit $25 $10 $10 n/a
Specialist visit $35 $30 ü $20 n/a
Prescriptions
Generic drugs $17* 1A - $4, 1B - $10 no charge n/a
Preferred brand name drugs $50 ü 25% ü $15 n/a
Non-preferred brand name drugs 50% ü 50% ü $50 n/a
Specialty drugs 50% ü 20% ü $50 n/a
Emergency Room (ER) visit 20% ü $100/10% ü $75 n/a
Inpatient hospital stay 20% ü 10% ü no charge n/a
Other service: Laboratory Services 20% ü no charge ü no charge n/a
Other service: X-rays and Diagnostic Imaging 20% ü 10% ü $20 n/a
Option 1 Option 2 Option 3
Insurance company Humana Blue Care Network of MI Total Health Care USA
Health plan name Silver 4600/Detroit HMOx Metro Detroit HMO Silver Totally You (Silver)
Plan type (HMO, PPO, POS, EPO, or other) HMO HMO HMO
Monthly premium (after tax credit) $36 $73 $96
Deductible (medical/drug or combined) $1,000 (combined) $350 (combined) $0
Out-of-Pocket Maximum (OOP Max) $1,500 $1,000 $1,500
Health Care Providers In Network/Covered? In Network/Covered? In Network/Covered?
Current doctor/provider: D. Willens, MD û û û
Other provider or hospital: # of oncologists
Current prescription drugs: metformin
Scenario 1: James and Ann (married couple)

67. 67
Copays/Coinsurance Amount Amount Amount
Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes)
Primary Care Provider (PCP) visit $25 $10 $10 n/a
Specialist visit $35 $30 ü $20 n/a
Prescriptions
Generic drugs $17* 1A - $4, 1B - $20 no charge n/a
Preferred brand name drugs $50 ü 25% ü $15 n/a
Non-preferred brand name drugs 50% ü 50% ü $50 n/a
Specialty drugs 50% ü 20% ü $50 n/a
Emergency Room (ER) visit 20% ü $100/10% ü $75 n/a
Inpatient hospital stay 20% ü 10% ü no charge n/a
Other service: Laboratory Services 20% ü no charge ü no charge n/a
Other service: X-rays and Diagnostic Imaging 20% ü 10% ü $20 n/a
Option 1 Option 2 Option 3
Insurance company Humana Blue Care Network of MI Total Health Care USA
Health plan name Silver 4600/Detroit HMOx Metro Detroit HMO Silver Totally You (Silver)
Plan type (HMO, PPO, POS, EPO, or other) HMO HMO HMO
Monthly premium (after tax credit) $36 $73 $96
Deductible (medical/drug or combined) $1,000 (combined) $350 (combined) $0
Out-of-Pocket Maximum (OOP Max) $1,500 $1,000 $1,500
Health Care Providers In Network/Covered? In Network/Covered? In Network/Covered?
Current doctor/provider: D. Willens, MD û û û
Other provider or hospital: # of oncologists 33 (10 mi.), 69 (20 mi.) 49 (10 mi.), 174 (25 mi.) 17 (10 mi.), 96 (25 mi.)
Current prescription drugs: metformin
Scenario 1: James and Ann (married couple)

68. 68
Scenario 1: James and Ann (married couple)

69. 69
Scenario 1: James and Ann (married couple)

70. 70
Scenario 1: James and Ann (married couple)

71. 71
Scenario 1: James and Ann (married couple)

72. 72
Scenario 1: James and Ann (married couple)

73. 73
Copays/Coinsurance Amount Amount Amount
Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes)
Primary Care Provider (PCP) visit $25 $10 $10 n/a
Specialist visit $35 $30 ü $20 n/a
Prescriptions
Generic drugs $17* 1A - $4, 1B - $20 no charge n/a
Preferred brand name drugs $50 ü 25% ü $15 n/a
Non-preferred brand name drugs 50% ü 50% ü $50 n/a
Specialty drugs 50% ü 20% ü $50 n/a
Emergency Room (ER) visit 20% ü $100/10% ü $75 n/a
Inpatient hospital stay 20% ü 10% ü no charge n/a
Other service: Laboratory Services 20% ü no charge ü no charge n/a
Other service: X-rays and Diagnostic Imaging 20% ü 10% ü $20 n/a
Option 1 Option 2 Option 3
Insurance company Humana Blue Care Network of MI Total Health Care USA
Health plan name Silver 4600/Detroit HMOx Metro Detroit HMO Silver Totally You (Silver)
Plan type (HMO, PPO, POS, EPO, or other) HMO HMO HMO
Monthly premium (after tax credit) $36 $73 $96
Deductible (medical/drug or combined) $1,000 (combined) $350 (combined) $0
Out-of-Pocket Maximum (OOP Max) $1,500 $1,000 $1,500
Health Care Providers In Network/Covered? In Network/Covered? In Network/Covered?
Current doctor/provider: D. Willens, MD û û û
Other provider or hospital: # of oncologists 33 (10 mi.), 69 (20 mi.) 49 (10 mi.), 174 (25 mi.) 17 (10 mi.), 96 (25 mi.)
Current prescription drugs: metformin
Scenario 1: James and Ann (married couple)

74. 74
Copays/Coinsurance Amount Amount Amount
Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes)
Primary Care Provider (PCP) visit $25 $10 $10 n/a
Specialist visit $35 $30 ü $20 n/a
Prescriptions
Generic drugs $17* 1A - $4, 1B - $20 no charge n/a
Preferred brand name drugs $50 ü 25% ü $15 n/a
Non-preferred brand name drugs 50% ü 50% ü $50 n/a
Specialty drugs 50% ü 20% ü $50 n/a
Emergency Room (ER) visit 20% ü $100/10% ü $75 n/a
Inpatient hospital stay 20% ü 10% ü no charge n/a
Other service: Laboratory Services 20% ü no charge ü no charge n/a
Other service: X-rays and Diagnostic Imaging 20% ü 10% ü $20 n/a
Option 1 Option 2 Option 3
Insurance company Humana Blue Care Network of MI Total Health Care USA
Health plan name Silver 4600/Detroit HMOx Metro Detroit HMO Silver Totally You (Silver)
Plan type (HMO, PPO, POS, EPO, or other) HMO HMO HMO
Monthly premium (after tax credit) $36 $73 $96
Deductible (medical/drug or combined) $1,000 (combined) $350 (combined) $0
Out-of-Pocket Maximum (OOP Max) $1,500 $1,000 $1,500
Health Care Providers In Network/Covered? In Network/Covered? In Network/Covered?
Current doctor/provider: D. Willens, MD û û û
Other provider or hospital: # of oncologists 33 (10 mi.), 69 (20 mi.) 49 (10 mi.), 174 (25 mi.) 17 (10 mi.), 96 (25 mi.)
Current prescription drugs: metformin yes (tier 1 & 2) yes (tier 1A) yes (tier 1 & 3)
Scenario 1: James and Ann (married couple)

75. • Cheapest monthly payment?
• Manageable deductible?
• Low copays/coinsurance?
• Having “first dollar” coverage? (i.e.
some services exempt from the
deductible)?
• Prescription drugs covered?
• Current doctor in network?
• Size of network?
Identify James’s and Ann’s Priorities for Insurance
75

76. 76
*Jennifer
can
be
claimed
as
a
tax
dependent
as
a
qualifying
relaRve
because
she
is
receives
more
than
half
of
her
support
from
her
parents
and
makes
less
than
$3,950
Scenario 2: the Green Family (family of 5)
Rosa
Dan
Jennifer*
Kristy
Cara
Age
43
43
20
16
10
County
(Zip
Code)
Greenville
County,
SC
(29607)
Income
$25,000
$20,000
$0
$0
$0
FPL
161
%FPL
Employer
coverage
no
no
no
no
no
Insurance
status
uninsured
uninsured
uninsured
on
Medicaid
on
Medicaid

77. 77
Scenario 2: the Green Family (family of 5)

78. Scenario 2: the Green Family (family of 5)
78
Applicant
Name:
Tax
Credit
(monthly):
Date:
Number
of
people
in
the
plan:
Eligible
for
cost-­‐sharing
reducCons?
□
No
□
73%
□
87%
□
94%
Marketplace
Plan
Comparison
Worksheet
Option 1 Option 2 Option 3
Insurance company
Health plan name
Metal tier (Bronze, Silver, Gold, Platinum)
Plan type (HMO, PPO, POS, EPO, or other)
Monthly premium (after tax credit)

79. Scenario 2: the Green Family (family of 5)
79
Applicant
Name:
Rosa, Dan, Jennifer Tax
Credit
(monthly):
$548.80
Date:
6/11/15
Number
of
people
in
the
plan:
3 Eligible
for
cost-­‐sharing
reducCons?
□
No
□
73%
ý
87%
□
94%
Marketplace
Plan
Comparison
Worksheet
Option 1 Option 2 Option 3
Insurance company
Health plan name
Metal tier (Bronze, Silver, Gold, Platinum)
Plan type (HMO, PPO, POS, EPO, or other)
Monthly premium (after tax credit)

80. Scenario 2: the Green Family (family of 5)
80

81. Scenario 2: the Green Family (family of 5)
81

82. Scenario 2: the Green Family (family of 5)
82

83. Scenario 2: the Green Family (family of 5)
83

84. 84
Copays/Coinsurance Amount Amount Amount
Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes)
Primary Care Provider (PCP) visit
Specialist visit
Prescriptions
Generic drugs
Preferred brand name drugs
Non-preferred brand name drugs
Specialty drugs
Emergency Room (ER) visit
Inpatient hospital stay
Option 1 Option 2 Option 3
Insurance company
Health plan name
Plan type (HMO, PPO, POS, EPO, or other)
Monthly premium (after tax credit)
Deductible (in-network/out-of-network)
OOP Maximum (in-network/out-of-network)
Other Considerations
Other Consideration:
Other Consideration:
Other Consideration:
Scenario 2: the Green Family (family of 5)

85. 85
Copays/Coinsurance Amount Amount Amount
Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes)
Primary Care Provider (PCP) visit no charge ü
Specialist visit no charge ü
Prescriptions
Generic drugs no charge ü
Preferred brand name drugs no charge ü
Non-preferred brand name drugs no charge ü
Specialty drugs no charge ü
Emergency Room (ER) visit no charge ü
Inpatient hospital stay no charge ü
Option 1 Option 2 Option 3
Insurance company Consumers’ Choice
Health plan name Bronze HDP 1
Plan type (HMO, PPO, POS, EPO, or other) EPO
Monthly premium (after tax credit) $0
Deductible (in-network/out-of-network) $11,000
OOP Maximum (in-network/out-of-network) $11,000
Other Considerations
Other Consideration:
Other Consideration:
Other Consideration:
Scenario 2: the Green Family (family of 5)

86. 86
Copays/Coinsurance Amount Amount Amount
Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes)
Primary Care Provider (PCP) visit no charge ü $40
Specialist visit no charge ü $150
Prescriptions
Generic drugs no charge ü $20
Preferred brand name drugs no charge ü $80
Non-preferred brand name drugs no charge ü $150
Specialty drugs no charge ü 20% ü
Emergency Room (ER) visit no charge ü 20% ü
Inpatient hospital stay no charge ü 20% ü
Option 1 Option 2 Option 3
Insurance company Consumers’ Choice Consumers’ Choice
Health plan name Bronze HDP 1 Bronze 10
Plan type (HMO, PPO, POS, EPO, or other) EPO EPO
Monthly premium (after tax credit) $0 $13
Deductible (in-network/out-of-network) $11,000 $12,600
OOP Maximum (in-network/out-of-network) $11,000 $13,200
Other Considerations
Other Consideration:
Other Consideration:
Other Consideration:
Scenario 2: the Green Family (family of 5)

87. 87
Copays/Coinsurance Amount Amount Amount
Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes)
Primary Care Provider (PCP) visit no charge ü $40 T1: $15, T2: $50 ~
Specialist visit no charge ü $150 $75 for 1/$75 ~
Prescriptions
Generic drugs no charge ü $20 T1 & 2: $20
Preferred brand name drugs no charge ü $80 T1 & 2: $45 ü
Non-preferred brand name drugs no charge ü $150 T1 & 2: $75 ü
Specialty drugs no charge ü 20% ü T1 & 2: 40% ü
Emergency Room (ER) visit no charge ü 20% ü $250 for 2/$250 ~
Inpatient hospital stay no charge ü 20% ü T1: $250, T2: $500 ü
Option 1 Option 2 Option 3
Insurance company Consumers’ Choice Consumers’ Choice Coventry
Health plan name Bronze HDP 1 Bronze 10 Bronze $15 Copay Upstate
Plan type (HMO, PPO, POS, EPO, or other) EPO EPO POS
Monthly premium (after tax credit) $0 $13 $56
Deductible (in-network/out-of-network) $11,000 $12,600 T1: $10,000/T2: $12,500
OOP Maximum (in-network/out-of-network) $11,000 $13,200 $13,200
Other Considerations
Other Consideration:
Other Consideration:
Other Consideration:
Scenario 2: the Green Family (family of 5)

88. 88
Copays/Coinsurance Amount Amount Amount
Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes)
Primary Care Provider (PCP) visit no charge ü $40 T1: $15, T2: $50 ~
Specialist visit no charge ü $150 $75 for 1/$75 ~
Prescriptions
Generic drugs no charge ü $20 T1 & 2: $20
Preferred brand name drugs no charge ü $80 T1 & 2: $45 ü
Non-preferred brand name drugs no charge ü $150 T1 & 2: $75 ü
Specialty drugs no charge ü 20% ü T1 & 2: 40% ü
Emergency Room (ER) visit no charge ü 20% ü $250 for 2/$250 ~
Inpatient hospital stay no charge ü 20% ü T1: $250, T2: $500 ü
Option 1 Option 2 Option 3
Insurance company Consumers’ Choice Consumers’ Choice Coventry
Health plan name Bronze HDP 1 Bronze 10 Bronze $15 Copay Upstate
Plan type (HMO, PPO, POS, EPO, or other) EPO EPO POS
Monthly premium (after tax credit) $0 $13 $56
Deductible (in-network/out-of-network) $11,000 $12,600 T1: $10,000/T2: $12,500
OOP Maximum (in-network/out-of-network) $11,000 $13,200 $13,200
Other Considerations
Other Consideration: out-of-network coverage? û û ü
Other Consideration:
Other Consideration:
Scenario 2: the Green Family (family of 5)

89. 89
Copays/Coinsurance Amount Amount Amount
Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes)
Primary Care Provider (PCP) visit no charge ü $40 T1: $15, T2: $50 ~
Specialist visit no charge ü $150 $75 for 1/$75 ~
Prescriptions
Generic drugs no charge ü $20 T1 & 2: $20
Preferred brand name drugs no charge ü $80 T1 & 2: $45 ü
Non-preferred brand name drugs no charge ü $150 T1 & 2: $75 ü
Specialty drugs no charge ü 20% ü T1 & 2: 40% ü
Emergency Room (ER) visit no charge ü 20% ü $250 for 2/$250 ~
Inpatient hospital stay no charge ü 20% ü T1: $250, T2: $500 ü
Option 1 Option 2 Option 3
Insurance company Consumers’ Choice Consumers’ Choice Coventry
Health plan name Bronze HDP 1 Bronze 10 Bronze $15 Copay Upstate
Plan type (HMO, PPO, POS, EPO, or other) EPO EPO POS
Monthly premium (after tax credit) $0 $13 $56
Deductible (in-network/out-of-network) $11,000 $12,600 T1: $10,000/T2: $12,500
OOP Maximum (in-network/out-of-network) $11,000 $13,200 $13,200
Other Considerations
Other Consideration: out-of-network coverage? û û ü
Other Consideration: Spanish speaking PCPs
Other Consideration:
Scenario 2: the Green Family (family of 5)

90. Scenario 2: the Green Family (family of 5)
90

91. Scenario 2: the Green Family (family of 5)
91

92. Scenario 2: the Green Family (family of 5)
92

93. Scenario 2: the Green Family (family of 5)
93

94. 94
Copays/Coinsurance Amount Amount Amount
Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes)
Primary Care Provider (PCP) visit no charge ü $40 T1: $15, T2: $50 ~
Specialist visit no charge ü $150 $75 for 1/$75 ~
Prescriptions
Generic drugs no charge ü $20 T1 & 2: $20
Preferred brand name drugs no charge ü $80 T1 & 2: $45 ü
Non-preferred brand name drugs no charge ü $150 T1 & 2: $75 ü
Specialty drugs no charge ü 20% ü T1 & 2: 40% ü
Emergency Room (ER) visit no charge ü 20% ü $250 for 2/$250 ~
Inpatient hospital stay no charge ü 20% ü T1: $250, T2: $500 ü
Option 1 Option 2 Option 3
Insurance company Consumers’ Choice Consumers’ Choice Coventry
Health plan name Bronze HDP 1 Bronze 10 Bronze $15 Copay Upstate
Plan type (HMO, PPO, POS, EPO, or other) EPO EPO POS
Monthly premium (after tax credit) $0 $13 $56
Deductible (in-network/out-of-network) $11,000 $12,600 T1: $10,000/T2: $12,500
OOP Maximum (in-network/out-of-network) $11,000 $13,200 $13,200
Other Considerations
Other Consideration: out-of-network coverage? û û ü
Other Consideration: Spanish speaking PCPs
Other Consideration:
Scenario 2: the Green Family (family of 5)

95. 95
Copays/Coinsurance Amount Amount Amount
Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes)
Primary Care Provider (PCP) visit no charge ü $40 T1: $15, T2: $50 ~
Specialist visit no charge ü $150 $75 for 1/$75 ~
Prescriptions
Generic drugs no charge ü $20 T1 & 2: $20
Preferred brand name drugs no charge ü $80 T1 & 2: $45 ü
Non-preferred brand name drugs no charge ü $150 T1 & 2: $75 ü
Specialty drugs no charge ü 20% ü T1 & 2: 40% ü
Emergency Room (ER) visit no charge ü 20% ü $250 for 2/$250 ~
Inpatient hospital stay no charge ü 20% ü T1: $250, T2: $500 ü
Option 1 Option 2 Option 3
Insurance company Consumers’ Choice Consumers’ Choice Coventry
Health plan name Bronze HDP 1 Bronze 10 Bronze $15 Copay Upstate
Plan type (HMO, PPO, POS, EPO, or other) EPO EPO POS
Monthly premium (after tax credit) $0 $13 $56
Deductible (in-network/out-of-network) $11,000 $12,600 T1: $10,000/T2: $12,500
OOP Maximum (in-network/out-of-network) $11,000 $13,200 $13,200
Other Considerations
Other Consideration: out-of-network coverage? û û ü
Other Consideration: Spanish speaking PCPs 19 (10 mi.) 26 (20 mi.) 19 (10 mi.) 26 (20 mi.) T1: 46, T2: 15 (10 mi.)
Other Consideration:
Scenario 2: the Green Family (family of 5)

96. Scenario 2: the Green Family (family of 5)
96

97. Scenario 2: the Green Family (family of 5)
97

98. 98
Copays/Coinsurance Amount Amount Amount
Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes)
Primary Care Provider (PCP) visit no charge ü $40 T1: $15, T2: $50 ~
Specialist visit no charge ü $150 $75 for 1/$75 ~
Prescriptions
Generic drugs no charge ü $20 T1 & 2: $20
Preferred brand name drugs no charge ü $80 T1 & 2: $45 ü
Non-preferred brand name drugs no charge ü $150 T1 & 2: $75 ü
Specialty drugs no charge ü 20% ü T1 & 2: 40% ü
Emergency Room (ER) visit no charge ü 20% ü $250 for 2/$250 ~
Inpatient hospital stay no charge ü 20% ü T1: $250, T2: $500 ü
Option 1 Option 2 Option 3
Insurance company Consumers’ Choice Consumers’ Choice Coventry
Health plan name Bronze HDP 1 Bronze 10 Bronze $15 Copay Upstate
Plan type (HMO, PPO, POS, EPO, or other) EPO EPO POS
Monthly premium (after tax credit) $0 $13 $56
Deductible (in-network/out-of-network) $11,000 $12,600 T1: $10,000/T2: $12,500
OOP Maximum (in-network/out-of-network) $11,000 $13,200 $13,200
Other Considerations
Other Consideration: out-of-network coverage? û û ü
Other Consideration: Spanish speaking PCPs 19 (10 mi.) 26 (20 mi.) 19 (10 mi.) 26 (20 mi.) T1: 46, T2: 15 (10 mi.)
Scenario 2: the Green Family (family of 5)

99. 99
Copays/Coinsurance Amount Amount Amount
Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes)
Primary Care Provider (PCP) visit no charge ü $40
Specialist visit no charge ü $150
Prescriptions
Generic drugs no charge ü $20
Preferred brand name drugs no charge ü $80
Non-preferred brand name drugs no charge ü $150
Specialty drugs no charge ü 20% ü
Emergency Room (ER) visit no charge ü 20% ü
Inpatient hospital stay no charge ü 20% ü
Option 1 Option 2 Option 3
Insurance company Consumers’ Choice Consumers’ Choice
Health plan name Bronze HDP 1 Bronze 10
Plan type (HMO, PPO, POS, EPO, or other) EPO EPO
Monthly premium (after tax credit) $0 $13
Deductible (in-network/out-of-network) $11,000 $12,600
OOP Maximum (in-network/out-of-network) $11,000 $13,200
Other Considerations
Other Consideration: out-of-network coverage? û û
Other Consideration: Spanish speaking PCPs 19 (10 mi.) 26 (20 mi.) 19 (10 mi.) 26 (20 mi.)
Scenario 2: the Green Family (family of 5)

100. 10
0
Copays/Coinsurance Amount Amount Amount
Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes)
Primary Care Provider (PCP) visit no charge ü $40 $10
Specialist visit no charge ü $150 20% ü
Prescriptions
Generic drugs no charge ü $20 $10
Preferred brand name drugs no charge ü $80 20% ü
Non-preferred brand name drugs no charge ü $150 20% ü
Specialty drugs no charge ü 20% ü 20% ü
Emergency Room (ER) visit no charge ü 20% ü 20% ü
Inpatient hospital stay no charge ü 20% ü 20% ü
Option 1 Option 2 Option 3
Insurance company Consumers’ Choice Consumers’ Choice Consumers’ Choice
Health plan name Bronze HDP 1 Bronze 10 Silver 10
Plan type (HMO, PPO, POS, EPO, or other) EPO EPO EPO
Monthly premium (after tax credit) $0 $13 $167
Deductible (in-network/out-of-network) $11,000 $12,600 $1,000
OOP Maximum (in-network/out-of-network) $11,000 $13,200 $3,000
Other Considerations
Other Consideration: out-of-network coverage? û û û
Other Consideration: Spanish speaking PCPs 19 (10 mi.) 26 (20 mi.) 19 (10 mi.) 26 (20 mi.) 19 (10 mi.) 26 (20 mi.)
Scenario 2: the Green Family (family of 5)

101. 10
1
Copays/Coinsurance Amount Amount
Deductible applies? (check if yes) Deductible applies? (check if yes)
Primary Care Provider (PCP) visit no charge ü $10
Specialist visit no charge ü 20% ü
Prescriptions
Generic drugs no charge ü $10
Preferred brand name drugs no charge ü 20% ü
Non-preferred brand name drugs no charge ü 20% ü
Specialty drugs no charge ü 20% ü
Emergency Room (ER) visit no charge ü 20% ü
Inpatient hospital stay no charge ü 20% ü
Option 1 Option 3
Insurance company Consumers’ Choice Consumers’ Choice
Health plan name Bronze HDP 1 Silver 10
Plan type (HMO, PPO, POS, EPO, or other) EPO EPO
Monthly premium (after tax credit) $0 $167
Deductible (in-network/out-of-network) $11,000 $1,000
OOP Maximum (in-network/out-of-network) $11,000 $3,000
Other Considerations
Other Consideration: out-of-network coverage? û û
Other Consideration: Spanish speaking PCPs 19 (10 mi.) 26 (20 mi.) 19 (10 mi.) 26 (20 mi.)
Scenario 2: the Green Family (family of 5)
$0 $2,004
Annual Cost Annual Cost
$6,400
$6,400
$40
$480
$4,124
$600
Health care needs: • PCP checkup every 3 months ($120/visit)
• Four generic prescriptions per month ($40 retail)
• Hospitalization ($4,000 bill)
$1,000

102. Identify the Green Family’s Priorities for Insurance
• Cheapest monthly payment?
• Manageable deductible?
• Low copays/coinsurance?
• Having “first dollar” coverage? (i.e. some
services exempt from the deductible?)
• Current doctor in network?
• Size of network
• Prescription drugs covered?
• Out-of-network coverage?
• Language spoken by providers?
• Lowest overall annual cost (premiums +
anticipated cost-sharing)
10
2

103. Interactive Exercise
Assisting Consumers in
Plan Selection

104. Assisting Consumers in Plan Selection
10
4

105. Scenario 1: Sasha (Tampa Bay Lightning Fan)
10
5
Sasha
Age
37
County
Hillsborough
County,
FL
Zip
Code
33601
Income
$25,000
Federal
Poverty
Level
212%
Employer
coverage?
no
APTC
$139.62/month
Cost-­‐sharing
ReducCons?
Yes
(Silver
73%)
Priorities
• Very concerned about cost
• Doesn’t have a specific doctor
• Has one prescription medication (generic)

106. B1
B2
B3
B4
QHPs available to Sasha (Tampa, FL) - Bronze
10
6

107. QHPs available to Sasha (Tampa, FL) - Bronze
10
7
B5
B6
B7

108. S1
S2
S3
S4
QHPs available to Sasha (Tampa, FL) - Silver
10
8

109. S5
S5
S7
QHPs available to Sasha (Tampa, FL) - Silver
10
9

110. Scenario 2: Jillian and Michael (Chicago fans)
11
0
Jillian
Michael
Age
55
55
County
Cook
County,
IL
Zip
Code
60609
Income
$22,800
$7,200
Federal
Poverty
Level
188%
Employer
coverage?
no
no
APTC
$603.77/month
Cost-­‐sharing
ReducCons?
Yes
(Silver
87%)

111. Scenario 2: Jillian and Michael (Chicago fans)
11
1

112. Contact Info
Dave Chandra
Senior Policy Analyst
202-408-1080
chandra@cbpp.org
For more information and resources, please visit:
www.healthreformbeyondthebasics.org
a
project
of
the
Center
on
Budget
and
Policy
PrioriRes,
www.cbpp.org
11
2

113. 113
New Training Resources
• Highly customized, Action-oriented
• New suite of training services
• Goal-setting
• Planning
• Coaching
• In-person training
• FOR MORE INFO –
training@enrollamerica.org