Plan Designs and Benefits

You’ve heard a lot of buzz about healthcare reform and now you want to know how it will affect you and your family! We’ve got the answers on everything you need to know about what’s new in the health insurance market.

What is packaged into an individual Qualified Health Plan?

Qualified Health Plans need to incorporate the following into their plan designs and benefits: 

  • Provide Essential Health Benefits: Coverage for ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance abuse services, including behavioral health treatment, prescription drugs, rehabilitative and habilitative services and devices, laboratory services, preventive and wellness services and chronic disease management, and pediatric services (including oral and vision care).
  • Preventive Services: Cover certain preventive services at no cost to you.
  • Maximum Out-of-Pocket Limits: These apply to the total out-of-pocket costs for EHB’s and covered benefits.
  • Annual and Lifetime Limits: There can be no limitations in regards to annual and lifetime dollar limits on essential health benefits
  • Metal Level: Plans offered for individuals must meet the Bronze (60%), Silver (70%), Gold (80%) and Platinum (90%) Metal Level, meaning this is the amount on average that the insurance carrier will pay for medical costs after premium payments. This calculation takes into consideration things such as your deductible, medical and prescription copays, coinsurance etc. The only exception in regards to an Metal Level tied to a qualified health plan is a Catastrophic Plan. Individual “Grandfathered” Plans do not need to meet the QHP standards. 
I am currently on an individual Grandfathered plan, what changes will impact me?
As an individual currently enrolled in a grandfathered plan, you can continue to keep your same plan and benefits as you have today, with minimal changes. The main impact on your grandfathered plan may be additional taxes and fees that will be packaged into your premiums.
What is an Individual “grandfathered” plan excluded from?

You can remain on your grandfathered individual plan if you choose to do so. The grandfathered individual plan you are on would not have to incorporate the following into their plan design(s):

  • 100% coverage of Preventive Care Benefits
  • Essential Health Benefits (EHB)
  • Deductible limits
  • Metal Level requirements
  • Limits on maximum out-of-pocket sharing
  • Removal of Pre-Existing conditions

Please visit for a complete list of exclusions for grandfathered plans.

Can I be disqualified from a health plan for pre-existing conditions?

No. There is also no risk assessment or health questions that can be used regarding whether or not a carrier will choose to offer you coverage. Your premiums can also only be based on the plan you choose, your age, geographic area, and tobacco status.

What is unique about a Catastrophic Plan?

Catastrophic plans will have lower premiums, protect against high out-of-pocket costs, and cover recommended preventive services without cost sharing—providing affordable individual coverage options for young adults and people for whom coverage would otherwise be unaffordable. 

Who is eligible?

  • Young adults under 30 years of age
  • Those who qualify for a hardship or affordability exemption and obtain an Exemption Certificate Number from the Marketplace

What is catastrophic coverage?

  • Plans with high-deductibles and lower premiums
  • Includes coverage of 3 primary care visits and preventive services with no out-of-pocket costs
  • Protects consumers from high out-of-pocket costs

The information provided above is for educational purposes only and not a substitute for professional advice. While Sanford Health Plan tries to keep the information as accurate as possible, health care information changes rapidly and thus this information should not be relied upon as comprehensive or error free. In no event will Sanford Health Plan be liable to you or anyone else for any decision made or action taken by you or anyone else in reliance upon the information contained on this page.