2018 - 2019 Reference Plan Guide€¦ · 2018 - 2019 Reference Plan Guide A Health Plan for...

2018 - 2019 Reference Plan Guide

A Health Plan for Angelenos by Angelenos…For All of L.A.

L.A. Care’s efforts to increasingly serve the diverse population and culture in Los Angeles County has earned it the Multicultural Health Care Distinction from the National Committee for Quality Assurance for the past four years. Now more than ever, L.A. Care is committed to delivering quality, affordable health care to all of L.A. County. As a community-inspired health plan, keeping your rates affordable helps us fulfill our mission and ensures that we are elevating health care…For All of L.A.

An Expanding Network That Creates Better Access to Care

L.A. Care continues to expand its provider network. Our network has 60 hospitals, 3,000 physicians and 1,700 pharmacies, including CVS and Rite Aid stores, and leading hospitals such as Children’s Hospital of Los Angeles, Good Samaritan Hospital and Huntington Memorial Hospital.

lacarecovered.orgFor Agent Support Call 1.855.248.7778

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L.A. Care Covered™ health plans are available in four primary levels of coverage: Bronze, Silver, Gold and Platinum. As the metal category increases in value, so does the percentage of medical expenses that a health plan covers, compared with what you are expected to pay in co-pays and deductibles. Plans in the higher metal tiers have higher monthly premiums, but you pay less when you need medical care. If you choose to pay a lower monthly premium, then you will pay more when you need medical care. You can choose the level of coverage that best meets your health needs and budget.

The breakdown of costs that you pay and costs the plan pays for the standard Bronze, Silver, Gold and Platinum tiers is shown below.

BRONZE60%

SILVER70%

GOLD80%

PLATINUM90%

Bronze: On average, your health plan pays 60 percent of your medical expenses and you pay 40 percent.

Silver: On average, your health plan pays 70 percent of your medical expenses and you pay 30 percent.

Gold: On average, your health plan pays 80 percent of your medical expenses, and you pay 20 percent.

Platinum: On average, your health plan pays 90 percent of your medical expenses, and you pay 10 percent.

Silver 70, Silver 73, Silver 87, and Silver 94 - The Silver HMO plans are the most popular plans if you visit your doctors frequently. The Silver plans provide a balance of monthly premiums, and cost-sharing subsidies for their benefits.

In some cases, individuals may qualify for an Enhanced Silver plan. This means that when they choose a Silver plan, they have – based on their income – enhanced out-of-pocket savings through lower co-pays, coinsurance and deductibles. Individuals in these savings categories get the benefits of a Gold or Platinum plan for the price of a Silver plan. In the three categories of Enhanced Silver, the plan pays either 94 percent, 87 percent or 73 percent of expenses, with the member being responsible for the rest.

Platinum 90 and Gold 80 - These plans are a great option if you visit your doctor often.

Plan Options

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L.A. Care Covered™ Benefits at a Glance

Primary Care Off ice Visits $15 $30 $40 $5 $15 $35 $756 0% 6

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The advantages of moving from Bronze 60 to Silver 94

Lower deductible – you start seeing coverage almost immediately Better benefits – lower out-of-pocket costs for services Savings on prescriptions The more you use the plan, the more you save

Sample 2019 Pricing Scenarios for Region 15

Bronze 60 Silver 94

Monthly Premium $263.27 $338.06

Monthly Estimated Financial Assistance $262.27 $290.03

Monthly Premium Out-of-Pocket Cost (Monthly Premium minus Estimated Financial Assistance)

$1.00 $48.03

Monthly Premium Out-of-Pocket Cost Differential (Silver Monthly Premiums minus Bronze Monthly Premium)

$47.03

Sample Scenario for 2019 Rates Annual income of $16,753 (FPL 138%) eligible for Tax Credit 40-year-old ZIP code 91770

Disclaimer: Estimates are subject to change based on qualifying criteria.

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Treatment for 1 condition Bronze 60 Silver 94 Cost Savings

Individual deductible, Medical/RX $6,300 /$500

$75/$0 -$6,225/$500

Individual Out-of-pocket maximum $7,550 $1,000 -$6,550

Out-of-Pocket Costs (5 Doctor Visits)

$510* $75 co-payment

$25 $5 co-payment

-$485

Out-of-Pocket Costs (2 Specialist Visits)

$285** $105 co-payment

$16 $8 co-payment

-$269

Treatment for 1 condition Bronze 60 Silver 94 Total Annual Cost Savings

Total Annual Costs (Premium + Utilization)

$807.00 $617.36 -$189.64

Sample Annual Utilization from Bronze 60 to Silver 94

*2 non-preventive, no deduct = 2 x $75.00, 3 non-preventive with deductible = 3 x $120**1 non-preventive, no deduct = $105, 1 non-preventive = $180.00

Annual Price Difference from Bronze 60 to Silver 94 (Treatment for 1 condition with 5 Primary Care Doctor Visits and 2 Specialist Visits)

For the Bronze 60 vs Silver 94 Total YEARLY Premium + Out-of-Pocket Costs Doctor + Out-Of Pocket Costs Specialist

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The advantages of moving from Silver 70 to Gold 80

No deductible -- you start receiving coverage immediately Better benefits -- lower out-of-pocket costs for services Savings on prescriptions The more you use the plan, the more you save

Silver 70 Gold 80


Financial Assistance $126.62 $126.62


$211.44 $225.65

Monthly Premium Out-of-Pocket Cost Differential(Gold Monthly Premium minus Silver Monthly Premium)

$14.21

Sample Scenario for 2019 Rates

Annual income of $30,350 (FPL 250%) eligible for Financial Assistance 40-year-old ZIP code 91770



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Sample Annual Utilization from Silver 70 to Gold 80

Annual Price Difference from Silver 70 to Gold 80 (Treatment for 1 condition with 5 Primary Care Doctor and Specialist Visits)

2019 Rates Silver 70 Gold 80 Cost Savings

Individual deductible, Medical/RX

$2,500/$200 $0/$0 No Deductible for switching to Gold

Individual Out-of-pocket maximum

$7,550 $7,200 -$350


$200 $40 co-payment

$150 $30 co-payment

-$50


$400 $80 co-payment

$275 $55 co-payment

-$125

Silver 70 Gold 80 Total Annual Difference


$3,137.28 $3,132.80 -$4.48

For the Silver 70 vs Gold 80 Total YEARLY Premium + Out-of-Pocket Costs Doctor + Out-Of Pocket Costs Specialist

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Bronze 60 Silver 94


Monthly Estimated APTC $281.16 $335.73


$1.00 $26.58

Monthly Premium Out-of-Pocket Cost Differential(Silver Monthly Premium minus Bronze Monthly Premium)

$25.58


Annual income of $16,753 (FPL 138%) eligible for Tax Credit 40-year-old ZIP code 90017

The advantages of moving from Bronze 60 to Silver 94

Less deductible – you start seeing coverage almost immediately Better benefits – lower out-of-pocket costs for services Savings on prescriptions The more you use the plan, the more you save


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Treatment for 1 condition Bronze 60 Silver 94 Cost Savings


$6,300/$500 $75/$0 -$6,225/$500


$7,550 $1,000 -$6,550


$510* $75 co-payment

$25 $30 co-payment

-$485

Out-of-Pocket Costs(2 Specialist Visits)

$285** $105 co-payment

$16 $55 co-payment

-$269

Bronze 60 Silver 94 Total Annual Cost Savings


$807.00 $359.96 -$447.04

Sample Annual Utilization from Bronze 60 to Silver 94

Annual Price Difference from Bronze 60 to Silver 94 (Treatment for 1 condition with 5 Primary Care Doctor Visits and 2 Specialist Visits)

*2 non-preventive, no deduct = 2 x $75.00, 3 non-preventive with deductible = 3 x $120 **1 non-preventive, no deduct = $105, 1 non-preventive = $180.00

For the Bronze 60 vs Silver 94 Total YEARLY Premium + Out-of-Pocket Costs Doctor + Out-Of Pocket Costs Specialist

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Silver 70 Gold 80


Monthly Estimated APTC $172.32 $172.32


$189.99 $205.22

Monthly Premium Out-of-Pocket Cost Differential(Gold Monthly Premium minus Silver Monthly Premium)

$15.23

The advantages of moving from Silver 70 – Gold 80

No deductible -- you start seeing coverage immediately Better benefits -- lower out of pocket costs for services Savings on prescriptions The more you use the plan, the more you save


Annual income of $30,350 (FPL 250%) eligible for Financial Assistance 40-year-old ZIP code 91770



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Sample Annual Utilization from Silver 70 – Gold 80

Annual Price Difference from Silver 70 – Gold 80 (Treatment for 1 condition with 5 Primary Care Doctor and Specialist Visits)

Treatment for 1 condition

Silver 70 Gold 80 Cost Savings


$2,500/$200 $0/$0 No Deductible for switching to Gold


$7,550 $7,200 -$350


$200 $40 co-payment

$150 $30 co-payment

-$50


$400 $80 co-payment

$275 $55 co-payment -$125

Silver 70 Gold 80 Cost Savings


$2,879.88 $2,887.64 $7.76

For the Silver 70 vs Gold 80 Total YEARLY Premium + Out-of-Pocket Costs Doctor + Out-Of-Pocket Costs Specialist

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L.A. Care will reward you for taking steps to improve your health!

Here’s how it works:

1 point = $1 in gift cards

Take your Health Appraisal survey. Get 40 points! Sign up for Health Coaching, create an action plan, and share

your progress. Get 25 points! Complete an online Tobacco Cessation workshop. Get 75 points! Complete an online Healthy Weight workshop. Get 75 more points!

***Please check qualifying rules for more information***

Rewards can only be redeemed if you are a current L.A. Care Covered™ member.

Boyle HeightsThe Wellness Center at the Old General Hospital1200 N State St., Suite 1069 Los Angeles, CA 90033

PacoimaIn The Zocalito Plaza10807 San Fernando Rd.Pacoima, CA 91331

InglewoodCorner of Century & Crenshaw3111 W. Century Blvd., Suite 100Inglewood, CA 90303

PalmdaleIn the Town Square2072 E. Palmdale BlvdPalmdale, CA 93350

Lynwood3200 E. Imperial HighwayLynwood, CA 90262

East L.A.4803 E. Whittier BlvdLos Angeles, CA 90022Coming in early 2019!

EARN UP TO $215

IN GIFT CARDS FOR MAKING HEALTHY CHOICES!

L.A. Care Family Resource Centers (FRCs) Are Your Centers for Health and Wellness

L.A. Care Family Resource Centers offer a fun and engaging space to learn, prevent, and improve your health! Each center offers free health education and exercise classes as well as a variety of other no-cost services*:

Health and developmental screenings** One-on-ones with a Registered Dietitian Medi-Cal and Covered California enrollment information Information on no-cost or low-cost health programs Classes for kids Child care service while you attend a class***

*Class dates and times vary by Center. Visit lacare.org/frc to view the monthly class schedule.**Health screenings vary location. Call for for more information. ***Limited child care is available at the Boyle Heights location. Please call for more information.

lacare.org/frc

L.A. Care Covered TM Added Value

2018 - 2019 Reference Plan Guide€¦ · 2018 - 2019 Reference Plan Guide A Health Plan for...

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