Highmark Advance Blue individual health insurance is no longer available in Western Pennsylvania. But affordable alternatives (such as the BCBS Shared Cost Blue 5500) are offered. The Advance Blue plan was a comprehensive policy that offered extensive coverage at an affordable rate for both individuals and families. Covered benefits included coverage that was often found in expensive group plans. However, premiums were very low on this particular plan.
We liked this policy because you did not have to meet the deductible to use the office visit and prescription benefits. The old Highmark DirectBlue and PPOBlue policies placed a deductible on those two coverages. Compared to many other available plans in Pennsylvania, the Advance Blue policy was able to potentially reduce your total out of pocket cash outlay since most claims were covered with small payments. Whether you had children or no dependents, it was a good choice.
So...since it is no longer available, what is the most affordable similar option? Meet "Shared Cost Blue PPO 5500, which is a Community Blue plan. Of course, there are no longer any medical questions to answer, since all Exchange policies are guaranteed-approval with no risk of denial because of pre-existing conditions.
If you need help with understanding Obamacare in Pa, we published a special page here that will provide specific and helpful information. You can learn about what is staying the same, what is changing, and how to easily enroll for a policy that you can afford.
Benefits of the Highmark BCBS Shared Cost Blue 5500
Visits to a primary care physician are subject to a $50 copay only. Thus, if the cost was $180, your out-of-pocket cost would be $50. There is also no limitation on the number of visits you or any family member can incur per year. Visits to specialists will be covered with a $90 copay and also with no limitations.
Preventive-related expenses and immunizations will not be subject to any copay or coinsurance. All Affordable Care Act (ACA) plans provide this feature, including all of the available Highmark policies. Other diagnostic testing and x-rays also do not have to meet a deductible. However, chiropractor expenses will typically only be covered for 60% of the cost. CT, MRI and PET scans are treated the same way.
There is a 40% copay on generic prescriptions, including mail-order. Brand-name drugs also have a 40% coinsurance, and, of course, should be avoided if possible. Out-of-network pharmacies are not covered. Occasionally, you will incur physician and/or surgeon fees along with specific facility fees. These types of expense are also covered with the identical 40% coinsurance.
Mental and/or behavioral and substance abuse outpatient services are subject to only a $90 copay. Typically, if treatment is inpatient, the 40% coinsurance applies. Also, pregnancy, including prenatal, postnatal and delivery are covered with the same 40%. This also includes home healthcare (if needed) and rehab-related services. Skilled nursing and durable equipment costs are also included in benefits.
Need dental or vision benefits for your child? It's covered! One routine eye exam, a pair of frames and two dental exams are provided each year without a copay or coinsurance. But you must use a Highmark-approved provider.
What's Not Covered?
Even under the Affordable Care Act, many items are often not covered. Some of the excluded benefits of the Highmark policy are private-duty nurses, acupuncture, cosmetic and bariatric surgeries, adult dental coverage, hearing aids, infertility treatment, and long-term care (which is available through individual policies). Although there are other exclusions, these are among the most likely to be used.
Of course, the mandatory "minimum essential coverage" is included, as required by ACA legislation. Although some of these benefits, such as mental illness and maternity may never be used, they can not be removed from the contract. It's possible that future law changes could allow policyholders to choose policies that don't contain benefits like these that may not be needed.
What About The Rates?
We'll give you an assortment of scenarios so you can understand how affordable prices are in Western Pa. We'll also use Allegheny county for our analysis.
25 year-old $25,000 income Rate is $115 per month.
35 year-old $35,000 income Rate is $139 per month.
45 year-old $40,000 income Rate is $165 per month.
55 year-old $50,000 income Rate is $254 per month.
25 year-old husband and wife with two children $40,000 income Rate is $102 per month.
35 year-old husband and wife with two children $50,000 income Rate is $210 per month.
45 year-old husband and wife with two children $60,000 income Rate is $330 per month.
55 year-old husband and wife with two children $70,000 income Rate is $441 per month.
55 year-old husband and wife with no children $70,000 income Rate is $508 per month.
Subsidies were included in all of the example above. The level and amount of your subsidy solely depends on your household income (including pensions and social security) and the number of persons in your household, including those that will not be covered. Upon request, we will calculate your amount of eligible financial aid and the policies that best utilize that help.