Insurance Department > Types of Coverage

adultBasic Benefit, Premium and Cost Changes

January 13, 2010 Press Release: Insurance Commissioner: Rising Costs Drive Urgent Need for National Health Care Solution

Letter sent to adultbasic enrollees

Due to increasing health costs, the Insurance Department needed to make modest changes to the benefit package and adjust monthly premium costs for the adultBasic program. This will enable as many people as possible to be enrolled in adultBasic. Additionally, the costs for those who are choosing to purchase coverage while on the waitlist will increase significantly. The Insurance Department recognizes that the changes in adultBasic may create additional burdens for people who have limited financial resources and are already struggling. However, given the increasing costs of health care and limited funding for the adultBasic program, the Insurance Department had to make these changes or it could not have covered the people enrolled in the program. We remain hopeful that federal health care reforms will soon make health insurance more affordable to all, including the people enrolled in adultBasic or on the waitlist.

The new premium rates and benefits listed below will be effective March 1, 2010. If you are receiving adultBasic coverage, the new premium payment amount will appear on your next bill. Please continue to pay your monthly premium so that your adultBasic coverage will continue. If you do not make the premium payment by the due date, your adultBasic coverage will end.

adultBasic Rate Changes

If you are now paying…	Effective July 1, 2010, you will pay…
$35.00 while enrolled in the program	$36.00
average $330.00 a month while purchasing coverage on the waitlist	$629.00

Below is a detailed summary of benefit and cost changes to the adultBasic program, effective March 1, 2010. Please note that this list includes only changes to the benefits and costs; otherwise, the program remains the same.

adultBasic Benefit and Cost Changes

	Old Benefit	New Benefit, Effective March 1, 2010
Primary care physician (PCP) office visits	$5 copay	$10 copay (except for preventive care)
Specialist doctor office visits	$10 copay	$20 copay
Emergency room copay	$25 copay	$50 copay
Inpatient hospital services	No charge	10% coinsurance/$1,000 maximum per year for all coinsurance Two stays per year
Physical, occupational and speech therapy	$2,500 maximum per year, combined	10% coinsurance/$1,000 maximum per year for all coinsurance 15 visits per year, combined
Diabetic supplies	No charge	10% coinsurance/$1,000 maximum per year for all coinsurance
Outpatient surgery (short procedure unit & facility)	No charge	10% coinsurance/$1,000 maximum per year for all coinsurance
Cardiac rehabilitation (36 sessions for a 12-week period)	No charge	10% coinsurance/$1,000 maximum per year for all coinsurance
Chemotherapy, dialysis or radiation	No charge	10% coinsurance/$1,000 maximum per year for all coinsurance
Pulmonary rehabilitation (18 sessions per calendar year)	No charge	10% coinsurance/$1,000 maximum per year for all coinsurance
Respiratory therapy (18 sessions per calendar year)	No charge	10% coinsurance/$1,000 maximum per year for all coinsurance
Home infusion	No charge	10% coinsurance/$1,000 maximum per year for all coinsurance
Home health care	No charge	10% coinsurance/$1,000 maximum per year for all coinsurance
Skilled nursing facility care (60 days per calendar year)	No charge	10% coinsurance/$1,000 maximum per year for all coinsurance
Inpatient rehabilitation therapy (45 days per calendar year)	No charge	10% coinsurance/$1,000 maximum per year for all coinsurance

Frequently Asked Questions
Who is affected by the changes to adultBasic benefits?

Currently, there are approximately 40,000 people enrolled in subsidized adultBasic (aB) and approximately 3,500 people who choose to purchase adultBasic coverage while on the waitlist. The changes to the adultBasic program will affect all of these people directly.

Will federal health reform help uninsured Pennsylvanians who cannot afford health insurance?

We expect federal health reform will help. Read Commissioner Ario’s comments regarding how federal health reform may help.

Who may I call with questions about my adultBasic coverage?

You may call your adultBasic insurance company. You will find their toll-free phone number on the back of your ID card.

Will there be a notice in the newspaper about the changes to the program?

The adultBasic insurance companies are sending notices directly to those enrolled in the program or purchasing benefits while on the waitlist. Publishing a notice in the newspaper would not have been as likely to reach everyone.

I read in the newspaper that adultBasic costs are going up and benefits are being reduced. I am enrolled with adultBasic and have not heard anything from my insurance plan. When will I hear from them?

Companies offering adultBasic are required to give 30 days notice of changes to premiums and/or benefits. You should receive a letter by the end of January. If you do not receive a letter from your plan, please call them directly, using the toll-free number on the back of your ID card.

Why did my adultBasic insurance plan send me a letter?

Whenever there is a change to your adultBasic benefits or premium, your plan is required to send you a letter. Please read this letter carefully, and direct any questions to your plan.

Premium Cost Increase Questions

Have the premium costs for adultBasic changed?

Yes. If you are enrolled in adultBasic now, you will pay $36 a month beginning on March 1, 2010. If you are on the waiting list and paying for adultBasic coverage, your costs will increase from approximately $330 a month to $600 a month beginning on March 1, 2010 and to $629 per month efective July 1, 2010.

Why are the monthly premiums for those purchasing the coverage while on the waitlist doubling in March?

The funds for adultBasic have remained relatively level; however, the costs of adultBasic (aB) health coverage have increased at a significant rate. In part, this is due to general “medical” inflation: medical appointments and procedures simply cost more than they used to. Another major reason for aB cost increases is that mnay of the people on the waitlist who access the benefit package tend to use medical services at a level much higher than in the commercial market. Because of these factors (general medical inflation plus significantly higher usage), the rates needed to be increased substantially to allow the program to continue covering as many people as possible. Legislation authorizing the aB program charges the Insurance Commissioner with the responsibility to make this decision.

How can adultBasic premiums for people who are paying while on the waitlist go up so much?

The adultBasic (aB) law requires the Insurance Department to administer the aB program, which includes entering into contracts with insurance companies to provide the coverage. New aB insurance contracts are effective January 2010. When the department looked at the benefits and the costs for the new aB insurance contracts (these are the contracts with the March 2010 premium increase), the rates needed to be increased substantially to allow the program to continue covering as many people as possible. Some changes in the benefits were also made to keep the rates from being even higher.

adultBasic is offered by several insurance companies across the state. Will the monthly subsidized and waitlist premium rate be the same for all of the companies that offer adultBasic?

Yes.

Are there any exceptions to the increased costs and decreased benefits for adultBasic enrollees?

Unfortunately, due to health care costs, the changes affect everyone enrolled in the program and on the waitlist.

I am on the waitlist and paying for adultBasic coverage while I wait. I can no longer afford the price. What are my options?

Additional resources can be found by clicking here.

How much is the monthly cost for adultBasic for a family?

Since adultBasic is an individual health insurance product, there is no “family” rate. If you have uninsured children, CHIP is available for children under age 19 and there is no waiting list for CHIP. You can go to www.compass.state.pa.us and apply for CHIP, as well as other social service programs.

Benefit and Cost Changes Questions

What adultBasic benefits change on March 1, 2010?

There are two specific changes to adultBasic benefits, aside from the cost changes:

Inpatient hospital stays will be limited to two stays per year
Physical, occupational and speech therapy will be limited to 15 visits per year, combined.

Otherwise, there have been no additional changes to the adultBasic benefit package.

Will my co-payments for services increase?

Yes. Primary Care Physician office visits will increase from $5 to $10 (except for preventive care); Specialist visits will increase from $10 to $20; and Emergency room visits will increase from $25 to $50 (waived, if admitted).

I see that coinsurance costs have been added to adultBasic. What is coinsurance and how does that affect me?

Coninsurance is the amount you are required to pay for a specific medical service that you receive. In the chart above, you’ll see that adultBasic recipients will be required to pay coinsurance for certain services they receive, up to a maximum of $1,000 per year. Services subject to coinsurance do not have copayments.

Is the coinsurance in addition to the existing copayments?

No. The coinsurance will be for all services listed in the chart, except those with copayments. The current copayments will be increased to:

$10 for PCP visit

$20 for Specialist visit

$50 for Emergency Room visits (waived, if admitted)

The coinsurance will be applied to all other inpatient and outpatient services listed in the chart above, to a maximum of $1,000 per year, excluding preventive care, ER visits, PCP visits and specialist visits.

Does my monthly premium payment count toward the maximum $1,000 coinsurance out-of-pocket expense?

No. Only the coinsurance payments go toward the $1,000 out-of-pocket expense.

Are physical therapy, occupational therapy, and speech therapy limited to 15 visits per therapy type (ie. 45 visits total) or 15 total visits for all therapy types?

The 15 visit annual limit includes covered outpatient physical, occupational and speech rehabilitation therapies for a total of 15 visits combined of all types per year.

Back to the adultBasic homepage.