Under provisions of the Patient Protection and Affordable Care Act (ACA), health care exchanges provide an online marketplace for standard health plans that must offer the same essential health benefits, enabling consumers to compare one company’s offering directly with another’s. But the ACA also provided for Innovative Qualified Health Plans that both meet the essential benefits and have additional features.
Although final approval is conditioned on a pending review by the Department of Consumer and Business Services, the action by Cover Oregon’s Innovative Committee is “an important step toward fulfilling our promise to listen to the people of Oregon and address their needs and desires for an understandable, affordable health plan,” according to Ralph Prows, MD, CEO of Oregon’s Health CO-OP.
“In developing our plans, we asked Oregonians, ‘If you could create your own health plan, what would it look like? And how would it treat you?’ ” Dr. Prows says. “They told us very clearly that they want better access to doctors by phone and email, and to naturopathic primary care. And they want plans with understandable out-of-pocket costs and no surprises. Paying coinsurance — a percentage of a charge they don’t know up front — is the kind of surprise they don’t want.”
As a result of those conversations, the CO-OP proposed four “SiMPLE” plans to be offered both on and off the marketplace exchange: SiMPLEgold, SiMPLEsilver, SiMPLEbronze and SiMPLEhighdeductible. Each parallels the health benefits of the comparable plan specified in the ACA, but also includes these features:
- Flat copayments ensuring members out-of-pocket costs for medical care are predictable. “If you visit a primary care provider, you know in advance it’s a flat copay. Nothing more,” Dr. Prows says. “If you visit a specialist, it’s a flat copay, nothing more. No surprising co-insurance bills showing up in the mail.”
- Coverage for follow-up or routine primary care consultations by phone or email, at a lower copayment.
- Deductibles only on big-expense items only: inpatient hospital stays, outpatient hospital procedures and ambulatory surgical center visits
- A choice of medical doctors or naturopathic physicians for primary care.
- Coverage of acupuncture for a specialty care copayment.
The review by the Department of Consumer and Business Services will determine if the plans contain the essential health benefits as defined by the ACA and meet other federal and state requirements. It is expected by end of June 2013.
