About the Health Care Plans Offered in Door County

Insurance plans are divided geographically with the Affordable Care Act exchange, and there are five insurance companies offering health care plans in Door County.

• Dean Health Plan
• Common Ground Healthcare Cooperative
• Arise Health Plan
• Molina Healthcare of Wisconsin
• Anthem Blue Cross Blue Shield

Each of those companies offers different plans, and there are 99 total options for Door County residents. The plans are split into five categories – catastrophic, bronze, silver, gold and platinum. All plans must cover the “10 essential benefits” (see bottom of page).

Catastrophic plans cover less than 60 percent of the cost of care, and are only available to people under 30 or with hardship exemptions (see bottom of page). Their deductibles are as high as $6,350 and individual monthly premiums are as low as $136. These plans cover three primary care visits per year at no cost and the free preventive benefits. Subsidies are not available for catastrophic plans.

Bronze plans have the lowest monthly rate, the highest deductible and the least amount of coverage ­­­– only about 60 percent of the cost of care. They generally offer deductibles in the $6,000 range, with a monthly family premium of about $650 and an individual premium of about $350.

Silver plans are the most flexible options because in most cases out-of-pocket costs can be subsidized as well as monthly premiums. Silver plans cover about 70 percent of the cost of care and most have deductibles that range from $2,000 to $4,500. Most of the plans also have 20 percent co-insurance after deductibles are reached, but those are capped at a maximum cost so you can continue getting care without paying co-insurance if you hit the maximum cost.

There are fewer gold and platinum plans offered in Door County, and the deductibles are typically in the $500 to $1,000 range with higher monthly premiums. Gold premiums for families start at $813 and go to $1,300, and individual premiums start at $410 and go to $650. Gold plans cover about 80 percent of the cost of care, and platinum plans cover about 90 percent.

Subsidies

Illustration by Ryan Miller.

Brian Stephens, revenue cycle director for Ministry Door County Medical Center, said about half of new enrollees in Door County will be eligible for subsidies, and silver plans may be the most affordable option for those with subsidies.

Before you decide on what level of coverage you’ll purchase, check to see if you’re eligible for an income-based subsidy. The Kaiser Family Foundation has an online tool to show your expected subsidy, and healthcare.gov has more information on plans.

Subsidies are available for those earning up to 400 percent of the Federal Poverty Level (FPL) – or up to $45,960 for an individual or $110,280 for a family of five. More subsidies are given to those making less. Individual adults and parents are eligible for BadgerCare with no premium if they earn up to 100 percent of the FPL, children under 19 are eligible for BadgerCare with no premium if their household income is under 200 percent of the FPL and pregnant women are eligible for BadgerCare with no premium if they make under 300 percent of the FPL.

Subsidies on monthly premiums are available for all plan levels, but are only offered on out-of-pocket costs for silver plans.

“With the silver level plans, not only are the premiums subsidized, but the deductible and co-insurance amounts are also discounted based on your income at that level,” Stephens said. “Especially for those who are being dropped from Medicaid and transitioning into a health insurance exchange plans, the silver plans will likely result in lower annual health care expenses than the bronze plans, even though the silver monthly premiums are just a little higher.”

Networks

After deciding on a level of coverage, look on insurance companies’ websites to see which doctors are included in the plans’ networks. Ministry Door County Medical Center doctors are networked with all Prevea 360 plans, the Common Ground Healthcare Cooperative’s Empower plan (not its Envision plan), all Arise plans and all Molina plans. Aurora doctors are networked with all Common Ground Healthcare Cooperative plans, all Arise plans, all Molina plans and all the Anthem Blue Cross Blue Shield plans.

The Community Clinic of Door County will still offer services to uninsured patients or those who can’t afford their deductibles.

Low-cost Plans

Stephens said the cheapest plan available to everyone in Door County is the Common Ground Healthcare Cooperative’s Envision plan at the bronze level. It has a $5,800 deductible and only includes Aurora providers and facilities.

“If you were to purchase this plan for your coverage you would still be able to see a MDCMC provider for your care, but your deductible would double to a whopping $11,600, making this option extremely unaffordable,” Stephens said.

The second cheapest plan offered in Door County is the Common Ground Cooperative’s Empower plan at the bronze level, which Stephens said also has a $5,800 deductible but offers a wider network of doctors that includes MDCMC, Aurora and most other local providers.

The third cheapest plan is Dean Health Plan’s Prevea 360. It has a $6,250 deductible, with a low premium, and covers MDCMC providers but not Aurora.