Platinum-tier Marketplace plans in Pa provide the best available medical coverage to individuals, families and small-business owners. The combination of low deductibles, copays and coinsurance, along with rich comprehensive benefits, makes these policies the “Cadillac” of Pennsylvania health insurance plans. Your maximum out-of-pocket expenses are low, and you won’t find a better policy anywhere. “No deductible” options are offered in some areas.
What Is A Platinum Plan?
When the “Patent, Protection And Affordable Care Act” (Obamacare) became law in 2010, (and upheld in a Supreme Cort ruling in 2012), a standardized method of comparing policies was enacted. “Metal” tiers were created, based on the actuarial value, or what percentage of your medical expenses were expected to be paid by the policy you were enrolling in.
Of all of the Metal tiers, the Platinum options offer the most complete coverage to pay for your medical expenses. Gold, Silver, Bronze, and Catastrophic contracts are also offered. 90% of your anticipated healthcare expenses (actuarial value) are expected to be paid, which included copays, coinsurance and deductibles. Special “cost-sharing,” however, is only available to Silver-ter plans. This feature can greatly reduce the deductible and out-of-pocket expenses to moderate and lower-income households.
Coinsurance And Deductibles
Since it is the most expensive “Tier” option, often coinsurance is 0% and deductibles are $1,000 and below. “0 deductible” options are also offered. The dollars you pay to physicians, specialists, hospitals, and other medical facilities are the lowest of all Marketplace policies. Therefore, persons with expensive chronic conditions, ongoing treatment and counseling, or annual recurring surgeries, often find this type of plan the most cost-effective. Also, if multiple expensive non-generic prescriptions are needed, this Tier is the best choice.
NOTE: Typically, these types of options are not the most appropriate for young adult medical coverage, unless there are severe chronic conditions present. If your child is under the age of 30, a more suitable plan may be a Catastrophic, Bronze, or Silver-tier contract because of lower cost and non-utilization of benefits.
Plans, Benefits And Prices
Below, we have listed the most comprehensive medical plans in Pennsylvania. All policies are offered by major carriers that are approved for Marketplace business. Platinum-level contracts most closely approximate the best employer-sponsored group coverage that is offered through several large companies. NOTE: In many situations, choosing a Gold-tier or Silver-tier (with cost-sharing) will be a more cost-effective choice. For the purpose of this article, we are focusing only on Gold and Platinum plans.
Advantage Platinum $250-$20 (UPMC) – $250 deductible with impressive $1,500 maximum out-of-pocket expense. $20 copay on primary care physicians, although deductible applies to specialists. Coinsurance is 10%, which begins after deductible is met. Generic, preferred and non-preferred drugs are only subject to copays ($10, $45, and $90).
Partner,” “Premium” and “Select” networks available. For children, an eye exam, glasses, and dental checkup (one per year-each) are covered. Cosmetic and bariatric surgery are not included in benefits. Also, adult dental and vision benefits are not included.
Advantage Gold $750/$10 (UPMC) – $750 deductible with maximum $3,000 out-of-pocket expenses. Office visit copays are $10 and $45. Most drugs are covered with copays ($10, $45, and $90 copays).
Comprehensive Care Flex Blue PPO 500 (Highmark) – $500 deductible with $1,650 maximum out-of-pocket expenses. Coinsurance is 10% after the deductible. Most prescriptions are subject to only a copay ($5, $20, and $45). Specialty drugs are subject to 50% coinsurance. Policy is offered as “Enhanced” or Standard.” Enhanced deductible is lower ($500 vs. $1,300) and coinsurance is also lower (10% vs. 40%).
Health Savings Blue PPO 1700 (Highmark) – Low $1,700 deductible with maximum $3,250 out-of-pocket expenses. Coinsurance is 10%. Since the cost is significantly more expensive than many other Gold-tier plans, if you are eligible for cost-sharing (Silver-tier only), this policy may not be cost-effective.
my Connect Blue EPO 250G (Highmark) – A Community Blue Flex plan, three separate network categories are available (Preferred, Enhanced, and Standard). Preferred option features $250 deductible with $10 and $60 office visit copays. The Urgent Care copay is $80. Tier 1, 2, 3, and 4 drugs are subject to 15%, 25%, 35%, and 50% of the cost of the prescription.
Healthy Benefits Value 0.0.10 (Keystone Health Plan Central – Capital Blue Cross) – $0 Deductible, although $6,850 maximum out-of-pocket. $10 and $25 office visit copays are nice but odd assortment of RX copys – $6, $42, $67, and $275 copays on generic, brand, non-preferred brand, and specialty drugs!
Health Benefits PPO 0.0.10 (Capital Blue Cross) – Similar to prior plan, although the PPO network is used instead of the HMO network.
Blue Shield Shared Cost 1500 (Highmark) – Multi-State plan with $1,500 deductible and $20 and $40 office visit copays. Deductible is $4,000 and policy is offered in the Gold tier. Generic and Preferred Brand drug copays are $10 and $50.
NOTE: The Highmark Health Savings Blue PPO 1400 is a very attractive Gold-tier option with a low $1,400 deductible and maximum $2,800 out-of-pocket maximum. Coinsurance is 10%. It is also offered in the Western portion of the state. Highmark’s Alliance Flex Blue PPO 1000 (Gold tier) offers a $1,000 deductible and low $10 and $20 office visit copays.
Coventry Gold $10 Copay OAHMO (Aetna) – Low $1,400 deductible with $10 and $40 office visit copays. Generic drug copay is also $10. Out-of-pocket maximum is $5,000.
Choice Marketplace PPO 25/50/100 (Geisinger) – $1,000 deductible with very low generic drug copay of $3. Office visit copays are $25 and $50 with overall $4,000 deductible.
NOTE: Both of these plans are issued in the Gold-tier. There are no Platinum-tier options available in the area.
Keystone HMO (Independence Blue Cross) – No deductible and $3,000 maximum out-of-pocket. Office visit copays are only $15 and $30 and all drugs avoid the deductible. Copays are $5, $30, and $40 on the three-tiers of drugs. This plan is one of the cheapest Platinum contracts in the Philadelphia area.
Personal Choice PPO (Independence Blue Cross) – No deductible and $2,500 maximum out-of-pocket. $10 and $40 office visit copays and identical drug coverage as previous plan.
Personal Choice PPO Complete (Independence Blue Cross) – No deductible with $2,000 maximum out-of-pocket. Smaller RX copays ($5, $20 and $30) than previous two plans.
Leap Specialty (Aetna) – Gold-tier option with $3,000 deductible and $3,000 maximum out-of-pocket expenses. Office visit copays are $10 and $75. Tier 1 and 2 drug copays are $5 and $50.
Choosing The Best Plan…For You
Is a “Platinum” tier option the best choice for you? Not always. Since subsidized “Silver” tier plans feature cost-sharing, for many households, they may be a better fit since they can potentially reduce out-of-pocket expenses by thousands of dollars. This is one of many reasons why accurately projecting your household income for the following calendar year, can save quite a bit of money.
By reviewing your budget, existing medical conditions (if applicable), federal subsidy qualification, and list of doctors and hospitals you prefer, we can recommend the ideal coverage for you. Each year, it is important to re-evaluate and compare new plan options, since so many changed typically occur.