2016 Virginia Health Insurance Exchange Marketplace Rates

The Virginia  Health Insurance Exchange (also referred to as a "Marketplace") begins Open Enrollment on November 1st for 2016 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 should be 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.


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.

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.

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 these benefits include maternity, prescriptions, preventive benefits, hospitalization and mental health.

You can not enroll in a Marketplace plan in Virginia unless it contains all 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 2016 student plans offered by colleges and universities no longer meet these requirements since their grandfathering period ended in September of 2015.

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'll 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 has approved five individual policies with an additional four currently being considered. 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, Buchanan County had only one company offering coverage for 2014. For 2015, there were two carriers -- HealthKeepers (Anthem) and Optima. Tazewell County only has one option for businesses. But private individuals and families had three options for 2015 (one more than 2014) as Anthem, Optima, and Aetna are active. Residents of Wythe and Bland counties will also have added additional options. 2016 has brought more policy choices.


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.

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.

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, 2016. 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.


Sample Virginia Health Insurance Marketplace Rates


Our sample prices are based on a three-person household (45 year-old parents and one child) in Arlington County with total adjusted gross income (AGI) of 50,000. The estimated federal subsidy of $439 has already been deducted from the premium. Illustrated are several of the most popular plans. Rates shown are monthly:


Bronze Tier


$106 -- BlueChoice HSA 6000 from CareFirst BC. $6,000 deductible with no coinsurance.

$120 -- Aetna-INOVA Deductible Only HSA from Innovation Health. $6,300 deductible with no coinsurance.

$130 -- HSA $4,000 from CareFirst BC. $4,000 deductible with 30% coinsurance on most coverage.

$143 -- Va 5000/30%/HSA from Kaiser. $5,000 deductible. $4,500 deductible also available for $160.

$181 -- KP VA Bronze 4500/50 from Kaiser. Flat $50 copay on BOTH primary-care-physician and specialist visits.


Silver Tier


$314 -- KP VA 1750/25%/HSA/Dental/Ped Dental from Kaiser -- $1,750 deductible with remaining benefits subject to coinsurance, copay, or deductible.

$339 -- Aetna-INOVA $10 Copay from Innovation Health -- $4,000 deductible with low $10 copay on PCP office visits. Copay on generic and brand drugs.

$351 -- KP VA 2500/30/Dental/Ped/Dental from Kaiser -- $30 and $50 copays on PCP and specialist visits.

$383 -- KP VA 1500/30/Dental/Ped Dental from Kaiser -- Similar to prior plan with $1,000 smaller deductible ($2,500 vs. $1,500).

$396 -- Aetna-INOVA $5 Copay 2750 from Innovation Health -- $2,750 deductible with only a $5 copay on PCP visits. Visit to a specialist is still $75.

$453 -- BlueChoice Plus $2500 from CareFirst BC -- $2,500 deducible with $20 copay on PCP visits and $10 copay on generic drugs.


Gold Tier


$531 -- Aetna-INOVA $5 Copay from Innovation Health -- Low $1,450 deductible with $5 copay on PCP visits. Specialist visits are also subject to a low $40 copay.

$547 -- BlueChoice Gold $1,000 from CareFirst BC -- $1,000 deductible with $3,750 maximum out-of-pocket limit. Also low $20 copay on PCP visits.

$574 -- KP VA 0/20/Dental/Ped Dental from Kaiser -- Great policy (one of our favorites). No deductible with $20 and $40 copays on office visits. Also, brand and specialty drugs subject to $30 copay only.


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 operate the Exchange. The same applies to smaller businesses (less than 100 employees). The "SHOP" will offer coverage and give employers an opportunity to select among numerous options.

The state will be involved with some of the management of plans,but essentially will play 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.


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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 were 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 is being spent on them.

Although their role is flexible, we believe they can best serve residents of the state that either have no internet 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 and reputable and reliable websites continue to be the best resources.


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.

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, 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.


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

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