Key Topics in Article:
- On-Marketplace & Off-Marketplace Plans
- Available Carriers in Texas
- Blue Cross Blue Shield Silver Plus 202 vs. Oscar Classic Silver Benefit Comparison
- Network size within Texas
The Affordable Care Act (ACA) was signed into law March 23, 2010 marking a shift into a new era of health insurance. Some of the most substantial changes were found in the standardization of plan designs and the level of benefits, like the implementation of the Essential Health Benefits (EHB). The standardization of plans left carriers to differentiate themselves through deductible, maximum out-of-pocket amounts and plan benefits.
Insurance carriers, like Blue Cross Blue Shield of Texas and Oscar, assigned new categories– known as metallic tiers–such as Bronze, Silver and Gold to different plan options. These tiers allowed consumers a simplified method to compare plans and understand the level of benefits for each tier.
Each metallic tier provides a different actuarial value, which is the percentage of total costs for covered benefits that will be paid by a health insurance plan. For example, a Silver plan is a category of health insurance policy that pays, on average, 70% of average policyholder’s health care expenses.
One popular aspect of the ACA was the EHB which mandates all health plans cover a range of important health benefits such as maternity, mental health, substance abuse and pediatric dental care. This provides policyowners with an increased level of benefits within the individual marketplace as compared to coverage prior to March 2010.
All individual Silver plans can be purchased either as “On-Exchange” with a subsidy, a government tax credit based on your annual household income, or “Off-Exchange” without a subsidy. If you’re eligible for and want to use the qualified subsidy to offset your monthly premium costs, On-Exchange plans are purchased through the government-created marketplaces, like the Federally-Facilitated Marketplace (healthcare.gov), or a state-based marketplace. Conversely, the Off-Exchange plans are offered privately by each health insurance company. The plan designs are basically the same, whether Off-Exchange or On-Exchange, with the number one benefit of shopping Off-Exchange being a simplified application process.
AVAILABLE TEXAS CARRIERS
Blue Cross Blue Shield is one of the most recognizable and trusted names in the health insurance industry. With over 90+ years of experience Blue Cross Blue Shield “believes Texas consumers deserve the best of both worlds: access to affordable, quality health care and top-notch service from a company that focuses solely on customers”. Blue Cross Blue Shield is unlike most of the national, publicly traded health insurance companies, because Blue Cross Blue Shield is customer-owned. This means the owners and customers are one and the same. Blue Cross Blue Shield is focused on long-term planning and investment strategies that deliver more stability and consistency to their customers rather than focusing on the bottom-line numbers for an investor’s quarterly report.
Oscar entered the Texas market with coverage introduced in the Dallas-metroplex area in 2018. The product launch in Texas was highly successful and resulted in expansion along IH 35 between Georgetown, Austin, San Marcos and San Antonio. Additional expansion has occurred in El Paso, Houston, Galveston county and Montgomery county. Since its inception in early 2012 “Oscar has been focused on one mission – to be a health insurance company centered around the patient, engaging members and guiding them to the right care.” Currently Oscar serves 15 counties throughout Texas and continues to aggressively grow within the state. Oscar has the most engaged members in the industry with the highest mobile engagement of any insurer. For 63% of Oscar’s members their interactions with the health care system are virtual and 41% of the members turn to the web and mobile apps every month. Oscar feels this activity positions them to be competitive in the Texas market, and that their tech friendly and concierge service appeals to all Texas consumers, whether tech savvy or not.
PLAN COMPARISON – Silver Plus 202 vs. Classic Silver
When comparing plans, or choosing between carrier options, consider both your health needs and your financial situation. Some of the most obvious differences between Oscar’s Classic Silver plan and Blue Cross Blue Shield’s Silver 205 is seen in the deductible amount, primary care & specialist care office visits, as well as the scope of the network.
The premiums are about halfway between the cheapest and most expensive options. However, Silver health plans offer a unique benefit, Cost-Sharing Reductions (CSR), which can reduce your health costs in addition to the subsidies. Cost-Sharing Reductions are extra savings that are available to those within a certain income range established by the Federal Poverty Level, who choose a Silver health plan. The reductions modify Silver health plans by lowering deductibles, copays and maximum out-of-pockets. The below chart details the Federal Poverty Level amounts, per household, that qualify for CSRs.
|Persons in Household||Federal PovertyLevel|
Health plans designate a specific deductible amount that, when the amount is met, initiates the co-insurance percentage amount you and the insurance carrier split for the remaining qualified medical expenses. However, if you qualify for a CSR, your deductible and maximum out-of-pocket may be reduced to a lower amount based on your income.
ACA health insurance plans typically have maximum out-of-pocket limits. After the amount has been met, the insurance carrier absorbs all covered costs for the remainder of the calendar year. With a Silver health plan and a CSR your maximum out of pocket amount can drop significantly. Additionally, policyowners with Silver CSR plans may also see a reduction in copays which means you will pay less each time you visit the doctor’s office.
Blue Cross Blue Shield has a significantly lower deductible ($1,100) compared to Oscar’s ($5,000). This can be an important factor in the decision-making process for many consumers because, if you expect to have many healthcare visits or require regular maintenance prescriptions you may choose a plan with a lower deductible. Those individuals maintaining regular prescriptions are often saddled with frequent office visits with their Primary Care Physician (PCP) or specialist physician.
Blue Cross Blue Shields provides policyowners a financial advantage, in comparison to Oscar, by establishing each PCP appointment at a $10 office visit copay while Oscar is a $50 copay. Unlike Blue Cross Blue Shield though, Oscar does not require a referral from your PCP before seeing a specialist.
Not only does Blue Cross Blue Shield require a PCP referral to see a Specialist, but the copay rate subject to any Specialist office visit has been established as 50% co-insurance only once the deductible has been met. Oscar has established each Specialist appointment at a $75 office visit copay which established a fixed, predictable amount for PCP visits.
The cost of generic prescription drugs varies slightly between the two carriers. Oscar provides policy owners $3.00 copay for Tier 1 generics compared to Blue Cross Blue Shield Tier 1 at $5.00. A larger price difference is seen in the Non-Preferred Tier 2 generics priced by Oscar at $25 compared to Blue Cross Blue Shield at $15. The variance of each carriers’ Tier 1 Preferred and Non-Preferred copay benefits, as well as physician office visits copays, should be factored into the overall cost analysis.
The most significant difference between Oscar and Blue Cross Blue Shield Silver plans is not found in the value of the policy benefits but in the scope of the network. Blue Cross Blue Shield is licensed in every county within Texas – all 254 – offering their policy owners a wide choice of doctors, hospitals and health care professionals. Blue Cross Blue Shield’s Blue Advantage Health Maintenance Organization (HMO), the largest network in that state, is comprised of over 69,000 health providers throughout more than 470 hospitals representing a total of 90% of Texas hospitals and 79% of Texas physicians. In comparison, Oscar has expanded to serve 15 counties throughout Texas, since entering the market in 2018, and has partnered with over 7 national hospital systems. Hospitals providing high quality health care affiliated with Oscar include Seton, Medical City, Hospital of Providence, HCA Houston Healthcare and Baptist Medical Center, as well as, the health providers associated with those systems.
Oscar makes it easy for members to manage their care online by offering Teledoc Services and assigning a Health Concierge Team to each policy owner. The Teledoc Service is a streamlined three step process that allows for policy owners access to talk or message with a board-certified doctor, at no cost, anytime 24/7. Oscar’s internal tracking indicates that for 43% of Oscar members, their first visit to the doctor is being routed through Oscar’s technology and customer service teams.
First, you will request a consultation by accessing your Oscar account, through either the smartphone app or online. The Teledoc service will even allow photo of the symptoms to be submitted to aid in the diagnosis. After submitting your request, you will then speak directly with a board-certified doctor and discuss your symptoms and diagnosis. Lastly, and together with the doctor, you will create an appropriate health plan and determine your prescription needs accordingly. With no trip to the doctor’s office or paying an office visit co-pay this can be both an efficient and time saving benefit.
In addition to the Teledoc Service, Oscar’s Health Concierge Team, comprised of “care guides” and a registered nurse, add further value by personalizing care through their in-depth client support and health resources. For example, your Health Concierge Team can help find local, in-network doctors, make recommendations on top-rated health care providers and even make appointments on your behalf. Whether it is an upcoming procedure or a routine appointment, your care team is informed and ready to support you.
BENEFIT COMPARISON TABLE
|BENEFIT||BLUE CROSS BLUE SHIELD SILVER PLUS 202||OSCAR|
|Network||Blue Advantage HMO||EPO|
|Primary Care Office Visit||$10 copay||$50 copay|
|Specialist Office Visit||Negotiated rate, 50% once deductible has been met||$75 copay|
|Emergency Room||$950 per occurrence, then 50% once deductible has been met||Negotiated rate, 50% once deductible has been met|
|Urgent Care||$15 copay||$100 copay|
|Inpatient Hospital Services||$850 per occurrence, then 50% once deductible has been met||Negotiated rate, 50% once deductible has been met|
|Outpatient Surgery Services||$600 per occurrence, then 50% once deductible has been met||Negotiated rate, 50% once deductible has been met|
|Outpatient X-Rays and Diagnostic Imaging||50%||Subject to deductible, 50% once deductible has been met|
(CT/PET scans, MRIs)
|50%||Subject to deductible, 50% once deductible has been met|
Preferred Generic / Non-Preferred Generic Preferred Brand / Non-Preferred Brand *
Preferred Specialty / Non-Preferred Specialty*
$5/$15 $10/$25* 45%/50% *
$3/$25 $75/ negotiated rate* Negotiate rate*
*Once deductible has been met. This is not a complete list of plan benefits. Please see carrier’s Summary of Benefits for additional information.
Every individual’s health need and financial situation is different, and because of that Stateside Insurance offers free head-to-head comparison for different health insurance plans. What may work well for one person could result in far higher cost for another. Ahead of purchasing a Silver health plan, or any other health plan, consult with one of our licensed insurance brokers. At Stateside Insurance we offer a wide range of ACA plans, both On and Off Marketplace, and will work with you to find the health plan that best first your needs.
STATESIDE CAN HELP!
Stateside Insurance Services, since 2003, has focused on providing comprehensive health insurance information, responsive customer service and expert industry knowledge for Texas consumers. Stateside has annually been recognized by health insurance carriers and the Health Insurance Marketplace as a Top Producer in Texas.
Whether the health insurance policy is for an individual, family, small business or supplemental Medicare coverage, Stateside dedicates the time, and our deep industry expertise, to ensure our clients have identified the best health insurance plan for their specific needs.
Stateside is available to answer any general questions regarding your coverage options, can provide a subsidy determination, and even assist in creating and submitting online applications for ACA compliant plans during an Open Enrollment or throughout Special Enrollment periods.
Phone Appointment Reservation.
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