QUALIFIED HEALTH PLANS (QHP) Flashcards
WHAT IS A QUALIFIED HEALTH PLAN?
Qualified Health Plans (QHP) are comprehensive, private health plans offered through the New York State of Health marketplace (NYSOH). These health plans have been certified by New York State and meet certain requirements, including providing you with care for essential health benefits and having enough doctors in your area.
WHO MAY QUALIFY TO PURCHASE A QHP?
you
may qualify to purchase a QHP, if:
- You are a New York State resident;
- You are a US/Naturalized Citizen or an immigrant present with the knowledge and consent of the US immigration service
- You are not eligible for Medicaid, Essential Plan or Child Health Plus.
HOW MUCH DOES A QHP COST?
The monthly premium you pay for a QHP will depend on the health plan you pick. You may be eligible to receive tax credits that can lower your monthly costs. Individuals earning up to $49,960 a year and a family of four can earn up to $103,000 a year may be eligible for tax credits. Your cost-sharing, or the amount you pay when you receive health care services including co-pays, co-insurance, and deductibles, will depend on the health plan you pick. However, once you reach your maximum out-of-pocket (moop) cost, the plan will pay 100% of your medical cost.
WHAT SERVICES WILL A QHP COVER?
A QHP will cover essential health benefits (EHBs), including:
- Free preventive care
- Inpatient care
- Outpatient services
- Maternity and Newborn Care
- Mental Health and Substance Abuse Disorders
- Emergency Services
_ Lab and Imaging
- Prescription drugs
- Rehabilitative and habilitative services
- Wellness and chronic disease management services
- Pediatric Services, including Oral and Vision Care
- Dental and Vision for children
WHAT IS ACTUARIAL VALUE?
The percentage of total average costs for covered benefits that a plan will cover. For example, if a plan has an actuarial value of 70%, on average, you would be responsible for 30% of the costs of all covered benefits. However, you could be responsible for a higher or lower percentage of the total costs of covered services for the year, depending on your actual health care needs and the terms of your insurance policy.
Actuarial Value is the percentage of costs a health plan covers for an average population in relation to how much the average enrollee is expected to pay.
NON-STANDARD PRODUCTS:
The non-standard products could have additional benefits beyond the EHBs, Actuarial Value (AV) equivalent substitution of some benefits, a different provider network, different prescription formularies, or AV equivalent variations.
- May offer a different network - They may have more, fewer or different providers then a standard QHP
- Have different, but AV equivalent, cost sharing - A consumer might want to have a type of cost-sharing reduction for a specific type of service (I.e. prescription drugs) as a part of the non-standard plans an insurance provider could offer.
EX: If a consumer takes a large amount of prescription drugs, but does not require primary care visits frequently, they may look for a non-standard plan with reduced drug cost and higher co-payment on primary care visits. - Additional Benefits above what is covered - Adult dental coverage is not part of the EHB package and therefore, not covered in standard QHPs. A non-standard plan could cover additional benefits, such as adult dental.
- Make limited substitutions in 2 benefit categories, but substitutions must be AV equivalent:
- Rehabilitative and habilitative
- Prevention/ wellness . chronic disease Management.
TIERED HEALTH PLANS:
Health plans in the NY State of Health Marketplace will be offered in a tiered format with several plans in each tier to choose from. Plan tiers will be based on Metal levels that match the percentage of costs covered (i.e. actuarial value of the plan) as follows:
Bronze - 60 percent
silver - 70 percent
Gold - 80 percent
Platinum - 90 percent
Actuarial value is the percentage of costs a health plan covers for an average population in relation to how much the average enrollee is expected to pay.
Premiums and out-of-pocket costs vary across metal levels. Bronze plans will have the lowest monthly premium and high out-of-pocket costs.
However, Platinum plans will have the highest monthly premiums with the lower out-of-pocket cost.
BRONZE ACTUARIAL VALUE?
60% of the cost of all EHB
SILVER ACTUARIAL VALUE?
70% of the cost of all EHB (Silver metal level may have out-of-network benefits.)
GOLD ACTUARIAL VALUE?
80% of the cost of all EHB
PLATINUM ACTUARIAL VALUE?
90% of the cost of all EHB (Platinum metal level may have out-of-network benefits.)
OUT-OF-NETWORK BENEFITS:
Remember, If out-of-network benefits are available, they would gbe in the Silver or Platinum metal levels; However, not every Silver and Platinum QHPs have this benefit available. All QHPs may offer different prescription formularies.
Non-standard plans may also offer different benefits, for example: Adult Dental.
