QHP – Coverage & Benefits

• Outpatient care;
• Emergency services;
• Hospital inpatient care;
• Maternity and prenatal care;
• Mental health and substance abuse disorder services, including behavioral health treatment, counseling, and psychotherapy;
• Prescription drugs;
• Rehabilitative and habilitative services, including physical and occupational therapy, speech-language therapy, psychiatric rehabilitation, and more;
• Labs;
• Preventive services; and
• Pediatric services, including dental and vision care for kids.

More information on federal EHB rules can be found here.

The State of Rhode Island also provides more detail to the EHB standards by naming an “EHB Benchmark Plan” for the State.  All QHPs in Rhode Island must cover the same services (or nearly the same services) as the EHB Benchmark Plan.

For 2017, the EHB Benchmark Plan in Rhode Island is BCBS VantageBlue.  This means that all QHPs must cover the same services as BCBS VantageBlue.  This does NOT mean that copays, deductibles, and other cost sharing must be the same as the VantageBlue plan.

A certificate of coverage for the EHB Benchmark Plan (BCBS VantageBlue) is available here – EHB Benchmark 2017 – VantageBlue.

Example 1
BCBS VantageBlue gold plan covers organ transplants.  There is no copay, but the enrollee must first meet her deductible before coverage applies.
→ Every QHP must also cover organ transplants because this is a service covered in the benchmark plan.  But some QHPs may apply copays or other cost sharing to organ transplants.

No Cost Preventive Care

All QHPs must provide full coverage for preventive care, with no out of pocket costs for the enrollee.

This means that QHP enrollees can all get an annual checkup, for example, without paying any money out of pocket.  QHPs cannot require enrollees to pay copays or meet deductibles before covering preventive services.

The list of preventive services that must be covered in this way is based on recommendations of the U.S. Preventive Services Task Force and other experts.

More information on which preventive services most be covered with no out of pocket costs is available here:

• Preventive services for adults;
• Preventive services for women;
• Preventive services for children.

Other Rules Applicable in all QHPs

All QHPs are also required to abide by the following rules:

• No exclusion of preexisting conditions;
• No higher premiums for women or people with preexisting conditions
• Premiums vary only by age);

• No lifetime or annual financial limits on coverage;
• Only financial limits are prohibited (e.g., $1 mil max coverage per year).  Other types of limits (e.g., 20 visits of PT per year) may be allowed.
• Eligibility of children until age 26;
• Rights to appeal benefit denials;
• Limited coverage of out-of-network emergency care (though this limited coverage may still leave enrollees with significant out-of-pocket costs);
• An appeal process allowing access to non-formulary medications when medically necessary;
• Parity between mental health benefits and medical/surgical benefits

What’s Different Between Different QHPs?

Bronze, Silver, and Gold (Metal Tiers)

QHPs are available in three different “metal tiers” – gold, silver, and bronze.

The difference between gold, silver, and bronze plans is the amount of out-of-pocket costs the enrollees have to pay when they get care.  Out-of-pocket costs include copays, deductibles, and coinsurance.

Gold plans offer the “best” coverage in terms of cost sharing.  Gold plans will typically offer lower deductibles, copays, and coinsurance than silver plans.  Likewise, silver plans offer “better” coverage in terms of cost sharing than bronze plans.

(“Catastrophic” plans offer similar cost sharing to some bronze plans, but they are generally only open to people under the age of 30.)

Within a given metal tier, the cost sharing will be similar in every plan.  So every gold plan will offer similar cost sharing to every other gold plan.

Not All Deductibles Are The Same

In some plans, deductibles apply to all services.  In other plans, deductibles only apply for a certain subset of services.  These differences can appear even between two plans offered by the same insurance company, and even within a single metal tier.

In general, the fewer services a deductible applies to, the better that will be for the enrollee.

Example 2
The 2015 NHP Community Silver plan has a deductible of $2,500 (for an individual) that applies to all services other than preventive care.  The 2015 NHP Value Silver plan has a deductible of $2,800 (for an individual), but the deductible only applies to inpatient care, imaging, lab services, skilled nursing, and outpatient surgery.
John is enrolled in NHP Community Silver, and Michelle is enrolled in NHP Value Silver.  Both John and Michelle go to see a dermatologist to check a funny looking mole (a specialist visit that is not preventive).  Neither has yet contributed anything towards their deductible.  The dermatologist bills $250 for the service.
→ John will have to pay the full $250 because he has not met his deductible, and specialist services are subject to the deductible in the Community Plan.
→ Michelle will only have to pay $40, the specialist copay for the Value plan.  In the Value plan, specialist office visits are not subject to the deductible.

The 2017 HSRI Plan Rate Sheet (available here) shows what services are subject to the deductible within each QHP.  The services highlighted in light brown are subject to the deductible, while those not highlighted are not.

Different Provider Networks

Another important potential difference between QHPs is the network of doctors, hospitals, and other providers who will accept that coverage on an in-network basis.  Different QHPs will cover different providers, especially if the QHPs are offered by different insurance companies.

HSRI offers an online provider directory during the enrollment process.  Through this directory, applicants can check to see if their doctors/hospitals accept each plan.

Different Out-of-Network Coverage

Some QHPs also offer out-of-network coverage, while others do not.

Different Drug Formularies

Different QHPs will cover different prescriptions.  Even among covered prescriptions, some plans will apply higher copays than others.

The list of prescriptions covered by a plan is called the “formulary.”  Formularies change regularly.

Applicants must check with each insurance company to determine which prescriptions will be covered and what the copays will be.

Different Insurance Carriers

Some consumers may have a preference for BCBS, NHP, or United based on their customer service or other factors.

Plan Design (differences within same tier, same carrier)

A single insurance company may offer more than one QHP within a single metal tier.  The biggest difference between these plans is usually the cost-sharing structure.

For example, in 2015 all three QHP insurers offered a plan on each metal tier that was qualified to work with a Health Savings Account (HSA).  These HSA-qualified plans tend to have lower deductibles (and lower premiums) than other plans offered by the same carrier on the same tier.  But the deductibles in the HSA-qualified plans apply to all services, while deductibles in the other plans apply to only some services.

Even though the HSA-qualified may be less expensive, they may not be for everyone.  HSA-qualified plans provide no coverage at all (other than preventive services) before the enrollee meets his deductible.

Cost / Premiums

Different QHPs also have different premiums.  The premium is the monthly cost that an enrollee must pay to stay covered.

Generally, premiums for QHPs in higher metal tiers will be higher premiums for QHPs in lower metal tiers.

Also, generally, premiums for HSA-qualified QHPs will be lower than premiums for non-HSA-qualified QHPs.

For each plan, the premium charged will vary according to the age of the enrollee.

More Resources:

• 45 CFR Part 147 (federal regulations on consumer protections that apply to all QHPs)
• 45 CFR Part 156, Subpart B (federal regulations on Essential Health Benefits)