Coverage Levels - Legacy Partners Insurance

2016 Covered California Health Insurance Plans

Covered California health insurance plans — and all health plans in the individual and small-group markets — are sold in four 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 insurance plan covers compared with what you are expected to pay in co-pays and deductibles. Plans in higher metal categories have higher monthly premiums, but when you need medical care, you pay less. Alternatively, you can choose to pay a lower monthly premium, and when you need medical care, you pay more. You can choose the level of coverage that best meets your health needs and budget.

Minimum coverage plan: If you’re under 30, you may be able to buy an additional health insurance plan option called minimum coverage plan. These plans usually have lower premiums and mostly protect you from worst-case scenarios. Minimum coverage plans through Covered California cover three doctor visits or urgent care visits, including outpatient mental health/substance use visits, with no out-of-pocket costs, and free preventive benefits. All other services will be full price but at the negotiated in-network price, until you spend $6,350, after which all in-network services are covered at 100 percent.
Bronze: On average, your health plan pays 60 percent and you pay 40 percent.
Silver: On average, your health plan pays 70 percent and you pay 30 percent. (In some cases, individuals may qualify for an Enhanced Silver plan. This means, based on their income, that when an individual chooses a Silver plan, they have out-of-pocket savings through lower co-pays, co-insurance and deductibles. Individuals in these categories get the out-of-pocket savings benefit of a Gold or Platinum plan for a Silver plan price. With an Enhanced Silver plan, on average, the plan pays 94 percent, 87 percent or 73 percent of expenses in total for covered benefits, with enrollees responsible for the rest.)
Gold: On average, your health plan pays 80 percent and you pay 20 percent.
Platinum: On average, your health plan pays 90 percent and you pay 10 percent.

Providing Information During the Application Process

Applicants will be asked to provide information about the members in their household who will be covered, as well as their home ZIP code and other details. In accordance with federal law, if consumers are seeking potential federal premium assistance, they will be asked to provide information during the enrollment process to verify income, citizenship and residency. This information includes:

Social Security numbers for U.S. citizens, or document information for immigrants with satisfactory status. Families that include immigrants can apply. Consumers can apply for their child or children even if they aren’t eligible for coverage.
Employer and income information for everyone in the consumer’s family. A family is defined as the person who files taxes as head of household and all the dependents claimed on that person’s taxes.
Federal tax information. If a consumer doesn’t file taxes, they can still qualify for free or low-cost insurance through Medi-Cal.
Proof of citizenship or lawful presence. Note that if an immigration document such as a legal permanent resident card does not have an expiration date, or it does not match the online application, consumers may use the following temporary values:

Card Number: ZZZ9999999999.

Expiration Date: 12/31/9999.

2016 STANDARD BENEFIT DESIGNS BY METAL TIER

MEDICAL COST SHARES
Coverage Category	Bronze	Silver	Gold	Platinum
	Covers 60% average annual cost	>Covers 70% average annual cost	Covers 80% average annual cost	Covers 90% average annual cost
Annual Wellness Exam	$0	$0	$0	$0
Primary Care Visit	$70	$45	$35	$20
Specialty Care Visit	$90*	$70	$55	$40
Urgent Care Visit	$120*	$90	$60	$40
Emergency Room Facility	Full cost until out-of-pocket maximum is met	$250 once medical deductible is met	$250	$150
Laboratory Tests	$40	$35	$35	$20
X-Ray and Diagnostics	Full cost until out-of-pocket maximum is met	$65	$50	$40
Deductible	Individual: $6,000 medical $500 drug Family: $12,000 medical $1,000 drug	Individual: $2,250 medical $250 drug Family: $4,500 medical $500 drug.	N/A	N/A
Annual Out-of-Pocket Maximum	$6,500 individual and $13,000 family	$6,250 individual and $12,500 family	$6,200 individual and $12,400 family	$4,000 individual and $8,000 family

Benefits shown in blue are not subject to a deductible.

*Copay is for any combination of the first three visits. After three visits they will be at full cost until the out-pocket-maximum is met.

DRUG COST SHARES – 30 DAY SUPPLY
Generic Drugs (Tier 1)	up to $500, after deductible is met	$15 or less	$15 or less	$15 or less
Preferred Drugs (Tier 2)	up to $500, after deductible is met	$50 after drug deductible	$50 or less	$15 or less
Non-preferred Drugs (Tier 3)	up to $500, after deductible is met	$70 after drug deductible	$70 or less	$25 or less
Specialty Drugs (Tier 4)	up to $500, after deductible is met	20% up to $250 after drug deductible	20% up to $250	10% up to $250

2016 STANDARD BENEFIT DESIGNS BY INCOME

MEDICAL COST SHARES
Coverage Category	Enhanced Silver 94	Enhanced Silver 87	Enhanced Silver 73
Eligibility Based on Income and Premium Assistance	Covers 94% average annual cost	Covers 87% average annual cost	Covers 73% average annual cost
Single Income Ranges	up to $17,655 (≤150%FPL)	$17,656 to $23,450 (>150% to ≤200% FPL)	$23,451 to $29,425 (>200% to ≤250% FPL)
Annual Wellness Exam	$0	$0	$0
Primary Care Visit	$5	$15	$40
Specialist Visit	$8	$25	$55
Urgent Care Visit	$6	$30	$80
Laboratory Tests	$8	$15	$35
X-Ray and Diagnostics	$8	$25	$50
Imaging	$50	$100	$250
Deductible	Individual: $75 medical Family: $150 medical	Individual: $550 medical $50 drug Family: $1,100 medical $100 drug	Individual: $1,900 medical $250 drug Family: $3,800 medical $500 drug
Annual Out-of-Pocket Maximum	$2,250 individual and $4,500 family	$2,250 individual and $4,500 family	$5,450 individual and $10,900 family
DRUG COST SHARES – 30 DAY SUPPLY
Generic Drugs (Tier 1)	$3 or less	$5 or less	$15 or less
Preferred Drugs (Tier 2)	$10 or less	$20 after drug deductible	$45 after drug deductible
Non-preferred Drugs (Tier 3)	$15 or less	$35 after drug deductible	$70 after drug deductible
Specialty Drugs (Tier 4)	10% up to $150	15% up to $150 after drug deductible	20% up to $250 after drug deductible

Benefits shown in blue are not subject to a deductible.