2018 Virginia Health Insurance Exchange Marketplace Rates

The Virginia  Health Insurance Exchange (also referred to as a "Marketplace") began Open Enrollment on November 1st for 2018 effective dates. Regardless of any pre-existing conditions, individuals, families and small businesses can apply for affordable medical coverage in Virginia from the top-rated companies. You can not be denied for medical conditions, and a special federal subsidy helps reduce premiums. Unless otherwise notified, you may keep the existing plan you have, or change policies.

About 900,000 Va residents are currently without coverage. About 800,000 persons are eligible for government assistance, either through the State Exchange or the expansion of Medicaid, if approved in the future by legislation. Raising the Federal Poverty Level requirements would allow more persons to qualify for low-cost (sometimes free) Medicaid. However, many states that have improved Medicaid expansion have seen costs rise, which is wreaking havoc on budgets. NOTE: Although Donal Trump's victory in the Presidential election will likely result in the repeal or replacement of Obamacare, significant changes will not likely occur until 2018 or 2019.

Preventative benefits are included on all policies without any out-of-pocket expense, waiting period, or deductibles to meet. Once your plan is effective, annual routine physicals, OBGYN visits, Paps, and mammograms may be immediately scheduled. Many shots, screenings, and other procedures are covered for both adults and children. Pediatric dental benefits are also typically covered, although adult dental benefits must be purchased separately.


What Type Of Plans Are Available?


There are four available types of policies. They are Platinum, Gold, Silver and Bronze. The expected percentage of medical claims covered under each policy is 60%, 70%, 80% and 90% respectively.  The Platinum is the "Cadillac" of the four choices, offering the lowest  out-of-pocket costs if you have a claim. The Bronze plan is the cheapest option, but you will incur higher charges when you submit a claim. However, it can be a big money-saver for persons that desire low premiums but are willing to assume more risk. NOTE: "Unreasonable premium increases" have reduced since the passage of the ACA legislation.

Also, a "Catastrophic" option is available for younger persons (under age 30) and applicants that have special financial needs. These policies are cheaper than other Metal plans but feature much lower benefits. You must be under age 30 to qualify for this type of low-cost plan. Exceptions are made if you meet specific financial hardship exceptions. Some examples include recently filing for bankruptcy, large unpaid medical bills, homelessness, victim of domestic violence, recent fire, flood or other natural disaster, death of a close family member, and your utilities have been shut off.

NOTE: If you qualify for a federal subsidy and your income does not exceed 250% of the Federal Poverty Level, a Silver-tier plan may be a better option than a Bronze or catastrophic option. "Cost-sharing" is only offered on Silver plans, and often allows you to dramatically reduce deductibles and copays. In those situations, it is much more cost-effective to select the Silver contracts. However, if your income significantly increases the following year, reviewing all options is recommended.

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Company And Plan Requirements


Companies offering 2018 Virginia health insurance plans through the Marketplace include CareFirst Blue Choice, Cigna, Group Hospitalization And Medical Services, HealthKeepers (Anthem), Kaiser, Optima, and Piedmont. The number of available companies has decreased from nine in 2017, to seven in 2018. UnitedHealthcare, Aetna, and Innovation Health no longer offer private individual and family coverage.


Each carrier must offer at least one Silver and Gold plan inside the State Exchange. By making these two options available, carriers are allowed to sell coverage "away" from the Exchange. Sometimes, contracts outside of the Marketplace will feature larger networks of doctors, specialists and hospitals with more competitive pricing (assuming you don't qualify for a subsidy). However, no subsidy applies, so generally, lower income households should not consider these policies.

Compliant plans are "standardized," and contain very similar core benefits. The federal government, when passing "The Affordable Care Act," felt there were too many choices for consumers to properly make an informed decision. A set of "essential health benefits," or core coverage, must be included in all policies. Some of the prominent benefits include maternity, prescriptions, preventive benefits, hospitalization and mental health.

You can not enroll in a Marketplace plan in Virginia unless it contains these 10 mandated benefits. If any are missing, the policy is "non-compliant," and you are subject to the special tax-penalty since you are considered "uninsured." Many student plans offered by colleges and universities previously did not meet meet these requirements until their grandfathering period ended. Therefore, Va Exchange options for students became very popular. Although these options are still popular, University plans must now contain these required benefits.

Non-Compliant Options

There are also policies that don't meet Obamacare requirements and are subject to the 2.5% household income tax penalty. However, in certain situations, paying the tax could be offset by the substantial savings of the plan premiums. But there may also be an unusually high deductible, which may be specifically what consumers are looking for. "Short-term" plans are non-compliant and subject to this penalty. But if you miss Open Enrollment and are not eligible for a "Special Enrollment Period" exception, they should be strongly considered since they are very cheap and can provide benefits until the next eligibility period.

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If only a few months of benefits are needed, then temporary medical plans would be the most appropriate. They will get you from Point A to Point B without putting a big dent in your budget. Prices are often about one-half to one-third the cost of a standard plan. But, as earlier discussed, since they are not ACA-approved, pre-existing conditions are not covered.

Are The Same Policies Offered In All Counties?

No. The SCC Bureau approves all policies in advance, and each year, new options are added. Separately, there are six options for small businesses. The vast majority of areas can choose among three or four options. But although there are still some specific areas where only a single policy can be chosen (The Southwestern part of the state), additional carriers are entering the Marketplace.

For example, in the Richmond area, only one company (Cigna) is available. In the Charlottesville, Norfolk, and Virginia Beach areas, only Optima Health offers plans. However, in Arlington, four options are offered, with plans available from CareFirst BlueChoice, CareFirst BlueCross BlueShield, Cigna, and Kaiser Permanente.


How And When Do I Buy A Policy


There is a standard online application that takes about 10-20 minutes to complete utilizing double-redirect software. Additional good news is there are no medical questions! You can apply for coverage through our website by first requesting a quote near the upper part of this page. Your eligibility is virtually guaranteed and you can apply alone or with live assistance. The choice is yours. Of course, there are no fees or extra charges to pay.

During the enrollment process, only basic information is needed, such as your name, address, phone number, email address, and dates of birth of all persons applying for coverage. Social security number and the name of the plan you are applying for will also be needed. And finally, if you are requesting a federal subsidy to reduce the rate, household income and employment information may be needed. Occasionally, citizenship may have to be verified if you recently moved to the US or Virginia.

If you are eligible for Medicaid or Medicare, there is a separate enrollment process. Medicaid eligibility guidelines have been expanded for lower-income residents of the state. Children may also be able to qualify for special low-cost or no-cost programs. The Department Of Medical Assistant Services administers Medicaid and CHIP, which is also known as FAMIS. There are both financial and non-financial requirements.

The Open Enrollment period began November 1st and runs through January 31. However, there are specific circumstances (triggering events) that will allow you to apply at any time. For instance, getting married, getting divorced, giving birth, or adopting a child will all qualify. If you wish to change from one Metal plan to another, (Bronze to Gold, Platinum to Silver etc...) you will have to wait until the next Open Enrollment. NOTE: These "triggering events" create an SEP (Special Enrollment Period) exception.


Virginia Health Insurance Marketplace Plans


Not all companies offer coverage in every county. Rates also vary, depending upon your age, county of residence, smoking status, and household income (federal subsidy eligibility). "Catastrophic" plans are available to applicants under age 30, or any person that meets "financial hardship" guidelines.


Cheapest va Marketplace Policies Offered

Bronze-Tier Plans Provide Low Rates


Catastrophic Tier


Kaiser KP VA Catastrophic 7350/0/Dental -- $7,350 deductible with maximum out-of-pocket expenses of $7,350 and 0% coinsurance. First three pcp office visits covered at 100%.

CareFirst BlueChoice HMO Young Adult 7350 -- $7,350 deductible with maximum out-of-pocket expenses of $7,350 and 0% coinsurance. First three pcp office visits covered at 100%.

Anthem HealthKeepers Catastrophic X 7350 -- $7,350 deductible with maximum out-of-pocket expenses of $7,350 and 0% coinsurance. First three pcp office visits covered with a $40 copay.

Optima Health OptimaFit Catastrophic 7350 -- $7,350 deductible with maximum out-of-pocket expenses of $7,350 and 0% coinsurance. First three pcp office visits covered with a $40 copay.


Bronze Tier


Anthem HealthKeepers Bronze X 6500 -- $6,500 deductible with maximum out-of-pocket expenses of $7,350 and 40% coinsurance.

Anthem HealthKeepers Bronze X 5250 -- $5,250 deductible with maximum out-of-pocket expenses of $7,350 and 35% coinsurance. Pcp office visits are subject to a $40 copay and all prescription drugs are subject to the deductible and coinsurance.

Anthem HealthKeepers Bronze X 5900 -- $5,900 deductible with maximum out-of-pocket expenses of $7,350 and 35% and 50% coinsurance. Pcp office visits are subject to a $35 copay for the first five visits. The generic drug copay is $30 ($75 for three month mail-order).

Anthem HealthKeepers Bronze X 4900 For HSA -- HSA-eligible plan with $4,900 deductible and maximum out-of-pocket expenses of $6,650 and 35% coinsurance.

Cigna Connect 6400 -- $6,400 deductible with maximum out-of-pocket expenses of $7,350 and 50% coinsurance.

Cigna Connect 6000 -- $6,000 deductible with maximum out-of-pocket expenses of $7,350 and 40% coinsurance. First three pcp office visits are subject to $20 copay (only). Urgent Care copay is $50. Preferred generic drug copay is $5 ($15 for 90-day mail order). Non-preferred generic drug copays are $35 and $105.

Kaiser KP VA Bronze 5500/50 -- $5,500 deductible with maximum out-of-pocket expenses of $7,350 and 35% coinsurance. $50 pcp office visit copay. Diagnostic test copay is $110 and generic drug copay is $25.

Optima Health OptimaFit Bronze 7200 20% M -- $7,200 deductible with maximum out-of-pocket expenses of $7,350 and 20% coinsurance. $40 and $60 office visit copays. Generic and preferred brand drug copays are $25 and $45.

Optima Health OptimaFit Bronze 6000 HSA -- HSA-eligible plan with $6,000 deductible and maximum out-of-pocket expenses of $6,550 and 10% coinsurance.

Piedmont Bronze Standard 6650 -- $6,650 deductible with maximum out-of-pocket expenses of $7,350 and 40% coinsurance. $35 and $75 office visit copays. Urgent Care copay is $75. The generic drug copay is $35 ($87.50 for mail-order).

Piedmont Bronze 6200 -- $6,200 deductible with maximum out-of-pocket expenses of $7,350 and 30% coinsurance. $45 pcp office visit copay for the first three visits. Prescription drugs are subject to copay and coinsurance.

Piedmont Bronze HSA 6000 -- HSA-eligible plan with $6,000 deductible and maximum out-of-pocket expenses of $6,550 and 30% coinsurance.


Silver Tier

Kaiser KP VA Silver 6000/35 -- $6,000 deductible with maximum out-of-pocket expenses of $7,350 and 35% coinsurance. $35 and $55 office visit copays with $55 Urgent Care copay. Diagnostic test copay is $50 and generic drug copay is $20.

Cigna Connect 6500 -- $6,500 deductible with maximum out-of-pocket expenses of $7,350 and 30% coinsurance. $15 pcp office visit copay. Urgent Care copay is $50. Preferred generic drug copay is $4 ($12 for 90-day mail order). Non-preferred generic drug copays are $25 and $60. Preferred brand drug copays are $60 and $180.



Gold Tier


$516 -- UnitedHealthcare Gold Compass 0 -- No deductible with $30 and $60 office visit copays.

$530 -- UnitedHealthcare Gold Compass 1000 -- $1,000 deductible but lower copays ($10 and $30) than previous plan. Maximum out-of-pocket expenses are the same ($6,850).

$554 -- Kaiser KP VA Gold -- $1,000 deductible with slightly lower maximum out-of-pocket expenses ($6,350). Office visit copays are $20 and $40.

$609 -- Innovation Health Leap Gold Basic -- $3,500 deductible with $10 pcp office visit copay. However, specialist copay is $75.


Platinum Tier


$685 -- KP VA 0/10/Dental/Ped Dental from Kaiser -- Similar to Gold-tier plan, although office visit copays are lower ($20 and $30). Since maximum out-of-pocket expense is $5,000 instead of $6,350, it's sometimes worth paying the extra premium.


Who Is Operating The Program?


The federal government is running the show, which is not unusual. Because of the large cost of handling the entire operation and transformation, many states are saving hundreds of millions of dollars by allowing the federal government to operate their Exchange. The same applies to smaller businesses (less than 100 employees). The "SHOP" Exchange offers coverage and gives employers an opportunity to select among numerous options. If you do not own a small business, there is no reason to utilize the SHOP Marketplace.

Virginia is involved with some of the management of plans, but essentially plays a backseat role. However, in the future, if the state government chooses, they can request to operate the Virginia Health Exchange Marketplace and take over the operation. A few years ago, Governor McDonnell discussed legislation regarding the state's roll, but no vote ever took place. Typically, because of the cost, individual states do not operate their own programs.


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What Are Navigators And Why Did Our State Get So Much Money For Them?


"Navigators" are not experienced licensed brokers that can compare and recommend the best plans for you. They are simply "workers" that are hired to help with the enrollment process of uninsured consumers. They typically are not licensed and their qualifications are very vague. They also may have access to your personal financial information. And yes, $2.5 million dollars was originally spent on them, with the total figure rising each year. Many budget-conscious residents of the state feel the funds should be spent elsewhere.

Although their role is flexible, we believe they can best serve residents of the state that either have no online access, or choose not to utilize the internet for comparing and applying for coverage. Also, it's possible that there are Virginia residents that do not have the needed transportation to travel, and will require an in-home visit. But experienced brokers along with their reputable and reliable websites continue to be the best resources for providing expert advice and customized recommendations.


Can I Keep The Policy That I Have Now?


Despite promises from various sources, not everyone can keep their existing plan. If your policy was "grandfathered,' (your carrier will notify you if it is), you can keep coverage without having to be forced to purchase new coverage. Although it will mean that your existing contract is lacking some essential mandated benefits, it still may be the best choice for you. NOTE: Your insurer can terminate the policy although written notification must be given. All grandfathered plans are expected to be terminated by 2017.

Another very distinct possibility is that your current company discontinues the specific plan you own. Generally, you are notified between August and November, which allows you plenty of time to research and compare new available options with all carriers. You do not have to enroll in the substitute option recommended to you by your current insurer. We help you choose the best policy from all available options.

Also, if your employer decides they are no longer offering medical coverage to their employees (and perhaps paying the fine instead), of course you would have to obtain new benefits. This specific risk was lessened a bit when the federal government waived the requirement in 2014 for certain businesses to offer healthcare to its workers. However, in 2015 and 2016, we have seen many employers discontinue their worker's benefits, or cut weekly hours from 40 to 35 or less.

What Are The "Cost-Sharing Plans?
These are found under the "Silver" Metal category of policies and it's a relatively unknown perk you can easily qualify for. If you are receiving any portion of the subsidy, you may automatically qualify for special reductions to your deductibles and copays. The maximum reduction is offered when the family Federal Poverty Level is less than 150%. FPL levels less than 200% will generate the next biggest savings.
Thus, if you are purchasing a policy with a $2,500 deductible, it's conceivable that it may be reduced to $2,000. Or perhaps $1,500 or lower. And other projected expenses would also reduce. For example, copays on prescriptions, Urgent Care visits and Emergency-Room visits often reduce by as much s 50%. It's a great way to save money throughout the year, but only the Silver options feature this benefit. Also, in many situations, the Silver-tier options are more attractive than Gold-tier options.

For instance, a 40 year-old residing in Fairfax that earns $40,000 would not qualify for a subsidy. However, with income of $22,000 the subsidy and subsequent "cost-sharing" reduces the deductible on the Innovation Leap Silver Basic plan from $5,250 to $1,570. Also, the deductible on the Kaiser KP VA Silver 2500/30 plan reduces from $2,500 to $0!


March 2014 -- Open Enrollment officially ends in three weeks, unless another extension is provided. Once it ends, consumers can continue to apply for medical coverage, although official Exchange plans will not be available. Short-term and Limited-Benefit policies will be two types of options offered.

April 2014 -- A private Marketplace may be created for Va residents later this year. The Senate Finance committee has given its approval in the budget that will provide an alternative to expanding Medicaid. The House is expected to review and vote on the proposal. The new legislation would keep costs down by requiring a copay and possible payment of up to 5% of their income in insurance premiums.

November 2014 -- Emergency legislation was approved that will allow more than 200,000 residents to retain their existing plan, even if it does not meet ACA guidelines by not containing the required 10 "essential health benefits." For many households, the alternative would have meant having to purchase a more expensive unsubsidized policy. Now, they can keep their older policies (for now), that often provide the specific benefits they want.

December 2014 -- The Centers For Medicare And Medicaid Services has awarded Virginia $2.6 million to help create an "Innovation Plan" that reduces the number of smokers, and increases coverage and treatment for mental illness. The grant is designed to help all residents, regardless of household income. Treatment of obesity, diabetes and cardiovascular/respiratory diseases will also be a major focus.

The VCHI and Lieutenant Governor Ralph Northam will assist in the development of accountable delivery systems that should show positive results very quickly. Hospitals and other facilities will be rewarded if improvements can be verified.

June 2015 -- 2016 Virginia Marketplace rates will be increasing. But how much? We're getting an early look, as carriers have filed their requests with the Department of Insurance, who must approve the price changes. Listed below are a small sample of these proposed increases:

59.1% -- Aetna Small Group
58.8% -- Innovation Health Aetna Fee For Service IH Small Group
34.6% -- Time Individual Medical
25.5% -- Group Hospitalization and Medical Services BluePreferred Multi-State Plan
18.9% -- CoventryOne POS Individual
14.8% -- Optima Vantage Equity
14.5% -- HealthKeepers HMO Off-Exchange

September 2015 -- Dominion Dental Services, who offers Marketplace dental benefits, is purchasing multiple companies, including DentaQuest Management, DentaQuest Virginia, and DentaQuest Mid-Atlantic. Virginia policyholders that have coverage through DentalQuest will be allowed to continue with a plan without a lapse in benefits. Many Medicaid recipients also are their customers. Final details of the agreement should be completed by the end of December.

About the author

Edward Harris

Virginia’s Premier Trusted Healthcare Authority With More Than 35 Years Of Experience Helping Consumers.