Community Health Insurance

Health insurance can be one of the largest expenses a community can face. With this in mind, we set out to determine what the best and most affordable option is for a group of 50+ people to choose. We researched, evaluated, and compared group insurance, company insurance, private/personal insurance, and creation of our own Medical Provider Network. We discuss what we learned with the following sections:

• What is Community Health Insurance
• Why Research and Open Source Community Health Insurance
• Ways to Contribute and Consultants
• Community Health Insurance Details
  • Medical Provider Network
  • Individual vs. Group vs. Company Insurance
  • Group/Company Health Insurance Options
• Understanding an HMO vs. PPO
  • HMO
  • PPO
• The Drivers That Increase Insurance Premiums
• Major Us Insurance Providers
  • Molina
• Comparison by Specific Offering (Deductible, Preferred Drugs, Physician, etc.)
• What We’re Going With and Why
  • Understanding Health Plans Change Every Year
• Projected Costs
  • Premiums
  • Deductibles
  • Trade-Off Between Premium and Deductible
  • Emergency Medical Scenarios
  • Importance of Having Insurance
  • Importance of Prevention
  • Community-Maximized Cost Savings
• Summary
• Resources
• Glossary
• FAQ

 

WHAT IS COMMUNITY HEALTH INSURANCE

In this case, the overarching goal of community health insurance is to develop a plan that will provide good health insurance to all of One Communities members, while minimizing the costs. The cost of health insurance will be the single most expensive expense for the community, so any opportunities for cost savings are vital. Therefore, One Community set out to identify the best and most affordable insurance options for groups of 50+ working and living together in the United States.

We have invested more than 250 hours researching all the options, contacting companies, and comparing plans both within insurance companies and between. A total of 43 insurance plans among 10 main insurance providers were analyzed, assessing costs, coverage, and services. We also have researched details of individual vs. group insurance, medical provider networks, and different types of plans.

Our selection criteria were based on the services, coverage, and associated costs. When researching each plan, we decided which plans provide the best options for the goals of this organization (taking into account an aging population, preventative checkups, dental accidents, catastrophic health events, high deductible) and compared them with plans from different insurance companies. Based on the criteria for the ideal plan, the potential choices were ranked based on their cost and benefits in order to find the best options for One Community populations.

 

WHY RESEARCH AND OPEN SOURCE
COMMUNITY HEALTH INSURANCE

It was important for us to identify the best insurance option for projects like ours because we want to provide excellent coverage and doing so will make health insurance the #1 most expensive ongoing expense for our entire project. In a sustainable environment like ours that reduces costs of other areas of life, when calculated over a period of 50+ years, health insurance will be more expensive than food, education, power, and construction combined!

Open sourcing our results is meant to teach others what our research uncovered as the best option, why it’s the best option, and to function as a benchmark for understanding the industry as it changes over time and selecting our insurance plan when we are ready. As long as insurance is needing to be purchased privately (vs. provided nationally), we expect this tutorial and research to be an invaluable resource for understanding the options and costs and choosing the right plan. Even if options radically change, reading this page should give you the information you need to be informed and set reasonable expectations for choosing your plan.

We’ll add here our specific plan details, costs, experience with providers, and everything else we learn as we purchase, maintain, and evolve our plan as part of the complete One Community rollout and construction process.

 

WAYS TO CONTRIBUTE TO EVOLVING THIS SUSTAINABILITY COMPONENT WITH US

SUGGESTIONS     ●     CONSULTING     ●     MEMBERSHIP     ●     OTHER OPTIONS

 

CLICK THESE ICONS TO JOIN US THROUGH SOCIAL MEDIA

 

 

RESEARCHERS FOR THIS COMPONENT:

Aidan Geissler: Sustainability Researcher
Noor Qureshi: Insurance Researcher
Yuran Qin: Web Designer

 

COMMUNITY HEALTH INSURANCE DETAILS

We discuss and compare the various insurance options and features with the following sections:

• Medical Provider Network
  • Establishing Your Own Medical Provider Network
  • Benefits Vs. Costs and Challenges of Establishing Your Own MPN
  • How to Establish a Medical Provider Network
  • Medical Provider Network
  • Individual vs. Group vs. Company Insurance
    • Individual, Group, and Company Insurance Options
    • Individual Insurance
    • Group Health Insurance Coverage
• Individual Insurance Options
  • Medicare
  • Special Note:Affordable Care Act (ACA) Plans
  • Hospital and Doctor Fixed Indemnity Plan (Fixed-benefit Insurance/Fee for Service Insurance)
  • Critical Illness Insurance/Accident Insurance
    • Critical Illness Insurance
    • Accident Insurance
• Group/Company Health Insurance Options
  • Fully-Insured Plans
  • Self-Funded Plans
  • Level-Funded Plans
  • Health Maintenance Organizations (HMOs)
  • Preferred Provider Organizations (PPOs)
  • Exclusive Provider Organizations (EPOs)
  • Point-of-service (POS) Plans
  • High-deductible Health Plans (HDHPs)/ Health Savings Accounts (HSAs)s
  • Catastrophic Plans

 

MEDICAL PROVIDER NETWORK

A medical provider network includes a network of providers that provide medical treatment for the injuries of employees. A medical provider network (MPN) can be established by a workers’ compensation insurer, self-insured employer, joint powers authority, the State, groups of self-insured employers, or any entity providing physician network services. Unless exempted by law or an employer, all medical care for workers insured on the job whose employer has an approved MPN will be provided through said MPN. Furthermore, employees who have injuries prior to the implementation of the MPN and who have not been transferred into the MPN are not eligible to use the MPN.

At a minimum, an MPN requires three primary treating physicians, 3 providers, and a written regional provider listing. A regional provider listing includes a list of all providers within a 15-mile radius of an employees’ worksite or residence. Once approved, a Medical Provider Network is operational for a four-year period. The network provider information should include the physician name, specialty, physical address, city, state, zip code, any MPN medical group affiliations, and an assigned provider code for each physician listed. A typical MPN application will include a description of the entity’s qualifications to be an eligible MPN application, proof of MPN eligibility, valid certificate of self-insurance (if a self-insured employer or joint powers authority), a documentation of legal status and licenses (if an entity providing physician network services), taxpayer identification number, name of MPN, the contact information of the MPN liaison to the Division of Workers’ Compensation (DWC), and a description of the MPN.

The MPN must be capable of handling the following: the expected number of claims, the ability to provide in the entire geographic region in which it aims to provide care to participants, the contact information of the MPN’s medical access assistant (person in charge of assisting employees with finding MPN physicians and scheduling appointments), the MPN website address, and the list of providers and their consent to being part of the MPN. An MPN can also include ancillary services, which is any provision of medical service by a non-physician (i.e interpreter services, physical therapy, and pharmaceutical services). If ancillary services are provided, the MPN must also include those providers and they will service the employees.

 

ESTABLISHING YOUR OWN MEDICAL PROVIDER NETWORK

A medical provider network (MPN) can be established by a workers’ compensation insurer, self-insured employer, joint powers authority, the State, groups of self-insured employers, or any entity providing physician network services. To establish one as a self-insured employer implies that you pay the claims of your employees yourself instead of paying an insurance company to pay medical, dental, and vision claims. In order to become self-insured, you must complete:

1. Feasibility study: Analyze past, payrolls, and premiums, and develop proposed claim levels for future years, which will eventually yield the conclusion of whether your company/group is capable of becoming self-insured.
2. State approval: Must submit an application for approval to become self-insured to the state. This application included audited financial data, prior workers’ compensation loss history, and other information required by the individual states.
3. Selection of Claims Administrator: To maintain a sustainable self-insured program, it is best to have a claims administrator/third party administration that plays a key role in managing claim dollars.
4. Loss Control: There must be a strong commitment to minimizing loss and making the workplace as safe as possible.
5. Excess Workers Compensation Insurance: Discuss the limits and self-insured retention to consider.
6. State security requirement: All states require a bond or letter of credit from self-insureds to guarantee payment of claims in the event the employer is unable to pay.

 

BENEFITS VS. COSTS AND CHALLENGES OF ESTABLISHING YOUR OWN MPN

For an organization like One Community, with the aim to create a sustainable civilization, it would be best to establish a Medical Provider Network. With a diverse set of people living in one community that aims to provide all the services of a real world, it would be best to have a network that contains a set of providers that are accessible to the villages and regulated by the organization. If this organization wishes to establish several different villages, it would be best to establish a Medical Provider Network as it is required that providers are located near the employee’s workplace or residence.

Medical provider network key points:

• DWC = Division of Workers’ Compensation: Monitors the administration of workers’ compensation claims and provides administrative and judicial services to assist in resolving disputes that arise in connection with claims for workers’ compensation benefits.
• MPN = Medical Provider Network: This is the network of providers (physicians and ancillary services) created to provide medical treatment for work injuries of employees
• All medical care for workers insured on the job whose employer has an approved MPN will be handled and provided through the MPN unless exempted by law or employer
• No requirement for employers or payors to use an MPN, it is up to the employer, insurer, or entity to establish and use the MPN to treat employees’ occupational medical care
• The MPN includes licensed physicians and providers of medical services
• MPN applicants determine which providers will be in their network

Who can have an MPN:

• Self-insured employers + workers comp insurers have an MPN
• An entity providing physician network services
• All employees of an employer except: those who properly pre-designate a physician before any injury occurs (even if physician is in network), employees with injuries prior to effective date of MPN whose care has not been transferred into MPN, those who are otherwise exempted from MPN by MPN insurer or employee

How to apply for an MPN:

• Submit an application (follow MPN regulations)
• Need MPN cover page
• Minimum of 3 primary treating physicians, 3 providers
• Need at minimum: written regional provider listing to be provided to covered employees (not just 5 or 10 providers)

Who is responsible for MPN:

• MPN applicant (regardless of any delegated authority)

 

HOW TO ESTABLISH A MEDICAL PROVIDER NETWORK:

Establishing a Medical Provider Network can be a very complicated process that requires several steps in order to be executed correctly. Below are the advantages of having a Medical Provider Network as well as the qualities of a good Medical Provider Network. The outline to sustaining a Medical Provider Network is also listed below. In order to qualify for a Medical Provider Network, one must fill out a form, which can be found on the division of workers compensation website.

Key points:

Advantages of a Network Management System:

• Easy and quick access to numerous options for healthcare
• Increased affordability to numerous options for healthcare
• Leading edge in current and emerging markets
• Greater transparency in pricing
• Higher quality of service
  • Careful attention should be given to the varying contracts between healthcare systems and practitioners when trying to establish a network
  • Strict regulation must be in place by the healthcare providers to provide consistent care across the network
  • Should retain providers and sustain important lines of communications and follow processes
  • Careful consideration must be paid to controlling the total cost of healthcare, quality of service provided, interests of the consumers

Cost of Healthcare/Network:

• Network cannot be designed around per visit costs → should be calculated around the entire costs of one healthcare episode (one medical illness can require the treatment of many doctors, and this is what should be taken into account when trying to keep costs of the network low)
• Calculate costs of the network in a more comprehensive manner

Quality of Service Provided:

• MPN should be able to gauge the quality of healthcare service
• Should be effective, patient-centered, timely, efficient, and equitable
• Evaluation of what providers to choose should not be based on the amount of time in the visit/duration of stay. Should focus on the details of care and the service provided
• Prioritize providers that perform well on these parameters

The Consumers:

• Make employees/consumers the priority
• Network created based on consumer preferences
• Get regular feedback from patients, direct consumer input opportunities, options for network preferences

Strong Supervisory Structure:

• Strong leadership capabilities
• Employ managers to oversee the authorities of the network and periodically assess the quality of the network
• Legal compliance needs to be monitored

Comprehensive Healthcare Provider Inclusions:

• Need a diverse range of doctors, physicians, and hospitals
• Network must include ancillary healthcare service providers, small clinics that are demographically diverse and provide scanning and image service centers
• Provide end to end services to consumer

IT systems:

• Requires solution-centric IT systems
• IT system should also be able to regularly update and maintenance protocol
• Should be able to track the quality of services rendered, cost of services, and intercommunications

Standardize the Processes:

• Network should be able to create and manage efficiencies without compromising on quality of safety of consumer
• Established verified and consistent processes
• Keep track of time involved in getting an appointment and duration of critical care
• Ensures that there is not a waste of services and unnecessarily high costs

High Clinical Standards:

• Maintain a standard quality across network
• Each provider should be provided with a check-list type method for ensuring that they comply with the standards the company wants out of its network
• Regular monitoring of the providers, patient feedback forms, etc.

Quality Selection of Providers:

• Choose providers with the highest standard of selection
• Medical credentialing
• Compile a profile on each provider that includes details of their operational methods
• Have the right mix of physicians, specialists, and ancillary care-givers

Standard Claims Processing:

• Ensure that billing processes and practices are uniform across providers and consumers
• Ensure that processes and costs are in line with the expected quality

→ Younger populations would be more inclined to a low-cost network, but an older population would be more inclined to a network that envelops larger health needs

When creating a network:

→ Take into account what consumers are looking for

→ Take in feedback from other established networks

→ Control costs with an increased efficiency without compromising consumer

→ Implement methods to analyze the network

→ Establish provisions that bypass the disadvantages of having a medical provider network:

• Managing the quality of care across the network
• Keeping costs low/unsustainable cost
• Inefficient information available
• Unorganized processes
• Lack of support
• Care misalignment

→ A robust healthcare provider network enables

• Mobility toward caregiving
• Connects the ecosystem of clinics, doctors, hospitals, and patientsCreate a functional platform for new models
• Safeguard patient information and data
• Enable high quality data exchange through mobile platforms

Steps to creating a sustainable Medical Provider Network:

1. Create a leadership structure
2. Include ancillary providers → rehabilitation centers, physical therapy, home health, infusion, ambulatory surgery centers and imaging centers
3. Have an IT system in place to share medical records as well as track quality and costs
4. Standardize care processes → patients should be able to use the network in a way that they are able to access all the care they need efficiently. This includes how long one waits until they get an appointment, how long it takes for a patient to get released → eliminate waste (such as follow-up visits)
5. Establish clinical standards → adopt evidence-based guidelines for care, guidelines such as when to send a patient to the ED or when to get a surgery
6. Choose physicians wisely → have a balance of specialists and physicians, do not accept physicians who won’t follow evidence-based criteria
7. Standardize claims processing → consistent billing practices across all providers
8. Monitor costs → hire auditors to determine if costs are in line with expectations
9. Monitor physician performance → have a profile on each physician, identify strengths and weaknesses in quality and efficiency→ track things such as how often do they prescribe brand-name over generic drugs, what types of surgery do they prefer (minimally invasive or open-cavity)
10. Work with payors: Payors can offer assistance in improving metrics → patient feedback

 

MEDICAL PROVIDER NETWORK:

If one visits an out-of-network provider, they will have to pay extra

• Molina: delivers managed health care services through Medicaid, Medicare, and the Health Insurance Marketplace → Cannot create your own MPN
• UnitedHealthcare: Yes employer can create own MPN
• Kaiser Permanente: Yes employer can create own MPN

All healthcare plans chosen were able to be provided by employers for individuals/families.

• Cigna Life insurance: No, but employer can coordinate across medical plans

 

INDIVIDUAL VS. GROUP/COMPANY INSURANCE

The type of health insurance an organization can buy depends on the characteristics of that organization. Often, with small business/organizations, one has the flexibility to choose between a traditional group plan or an individual plan. Individual Health insurance, which can be employee-sponsored or self-insured contain policies that an individual must purchase themselves. Group health insurance is employer-sponsored and is purchased by an employer and then offered to the employees as well as their dependents. With group health insurance, the employer selects the plan and offers it to employees. The premium cost is often split between the employer and employee where the employer must contribute a minimum percentage to the premium.

When it comes to purchasing a plan, there are several differences to note between individual insurance and group insurance. With group insurance, coverage is limited once a job is lost or changes. The choice of medical providers is limited and the employer chooses the plan. With individual health insurance, the coverage does continue when a job is lost or changes. There is more flexibility when it comes to one’s choice of medical providers as the individual can choose the carrier. With individual plans, the employee chooses the plan. In both types of plans, there are tax-deductible premiums and each plan provides coverage for preexisting conditions. Individual health insurance plans do tend to be on the cheaper side compared to group health insurance plans. Based on the below research, it would be best to go with an individual type of plan. When it comes to establishing a Medical Provider, it is much easier to create one under an individual plan as there is more flexibility as to who to add or delete from the network. With a group plan, employees most likely have to follow the Medical Provider Network established by the health insurance company.

Everyone qualifies for individual insurance, however for group insurance one must first qualify in order to be able to purchase the insurance. To be eligible for a small business, a company must have between one and 50 employees. If a company has more than 50 employees, that company/group must apply for large group coverage, meet the group coverage reporting requirements, and meet minimum group health insurance standards. Furthermore, at least one of the employees on the group health insurance plan cannot be an employer or owner. The second employee also cannot be the spouse/family member/partner of the owner or employer. The second employee cannot be a seasonal worker or a contract of the owner/employer. In order to be considered an employee one must be full-time or the full-time equivalent. (ex. 3 employees who each work 10 hours/week is the same as one full-time employee). Following that, all employees must pass the common-law test. In order to pass the common-law test, the owner has to have control over the work the person does and the way the person goes about doing work. It is okay to offer group health insurance to part-time and seasonal workers, but one must enroll at least 70% of the uninsured, full-time employees.

There are several circumstances under which one can combine different health insurance policies. In most cases, people who are usually under more than one health insurance plan tend to be under 26 and happen to be under their parent’s plan and another plan. In the case that one is under 2+ plans, there is usually one that is considered the primary insurance and one that is secondary. The primary insurance will pay for coverage up to its limits while the remaining bill goes to the secondary insurance. Both plans only cover up to their limits, so any remaining costs are up to the individual to pay. There are several pros and cons to consider when having multiple health insurance policies. Multiple health insurance policies means extra help with medical costs and an added safety net. One can also maximize the benefits from both plans and receive more coverage than if they were to have just one plan. One combination tactic is to combine primary health insurance policies with a catastrophic health plan. Catastrophic health plans are primarily for people who cannot afford actual plans, but these types of plans can be combined with a Health Savings Account, which can be tax advantageous. People can combine a Catastrophic plan with a health savings account as a way to invest their money. This is not a new approach, however, deciding to go this route is completely optional and not required. Catastrophic health plans are used for worst-case scenarios that are eligible for people under 30 or anyone with a hardship exemption or affordability exemption.

 

INDIVIDUAL, GROUP, AND COMPANY INSURANCE OPTIONS

Health benefits organized by the level of benefits they offer:

1. Bronze: covers 60% on average, you pay 40%
2. Silver: covers 70% on average, you pay 30%
3. Gold: covers 80% on average, you pay 20%
4. Platinum: most coverage, covers 90% on average, you pay 10%
5. Catastrophic policies: you pay after you have reached a very high deductible, covers first three primary care visits and preventive care for free, even if you have not yet met deductible

*Note that these are estimates that are determined by the Affordable Care Act, which requires each metal tier to cover a certain percentage cost.

 

INDIVIDUAL INSURANCE:

• For one’s self or family
• Individual more expensive than group health insurance, but offers more coverage

 

GROUP HEALTH INSURANCE COVERAGE:

• Purchased by an employer and offered to eligible employees of the company, and to eligible dependents of employees
• Limited=fixed medical benefits that help to pay for everyday medical expenses. Once one is no longer part of the group/company, they no longer have the same coverage they used to. Instead, they are under a Limited Medical coverage plan, which is considered supplemental insurance that has fixed benefits for every day medical expenses.

 

INDIVIDUAL INSURANCE OPTIONS

This section focuses on the various options one can choose from, if they decide to get an individual insurance plan. There are several different types of general plans one can choose from and each has its own features. These general plans are: Medicare, Affordable Care Act, Hospital and doctor fixed indemnity plan, and critical illness/accident insurance. Medicare is mainly for senior citizens and older people. The Affordable Care Act is usually for those who are of a lower income. The hospital and doctor fixed indemnity plan and critical illness/accident plans are usually supplemental insurance policies alongside a primary insurance plan. These plans are usually meant for younger populations that do not require an insurance plan that requires more extensive coverage. The benefits of having an individual insurance plan compared to a group/company insurance plan are outlined above. Amongst the different types of individual insurance plans, since each type of plan caters to different types of people, they offer different types of coverages. For an organization such as One Community, using a critical illness/accident insurance plan and pairing it with a more extensive plan would be beneficial. Since this organization aims to take into account an aging population that also considers a young population, the other types of insurance plans would be difficult to take into account the entire community.

 

MEDICARE

Medicare is a federal health plan for senior citizens, certain younger people with disabilities, or people with end stage renal disease. There are several different types of medicare plans outlined below, depending on the type of coverage one qualifies for. Since this plan is primarily geared towards the older population, it would not be best suited for a young group of employees. Following that, different medicare plans offered provide different costs and coverage. Medicare contains much more established health insurance policies with less flexibility and is focused towards a certain group of people.

 

KEY POINTS

• If you are 65+, or under 65 with a qualifying disability/condition
• Coverage in every medical area
• Medicare Part A: hospital insurance
• Medicare Part B: doctor visits/lab work
• Medicare Part C: Also known as Medicare Advantage, a plan where you pay a premium for Medicare Part B, but all of your benefits will be covered under a single plan from a private insurance company. These plans may also provide prescription coverage.
• Medicare Part D: prescription drug coverage. These types of plans are a joint collaboration between the federal government and a private insurance company.
• Enrollment is three months before and after the month you turn 65

5 types:

1. Original Medicare: Parts A&B
2. Medicare Advantage Plans: Part C
3. Dual Special Needs Plan (D-SNP): for individuals who have both Medicare and Medicaid, offer benefits and features beyond Original Medicare, can include transportation assistance and prescription drug coverage
4. Medicare Supplement Insurance Plan (Medigap): help cover some out-of-pocket costs not paid by Original Medicare
5. Medicare Prescription Drug Plans: Medicare Part D

 

SPECIAL NOTE: AFFORDABLE CARE ACT (ACA) PLANS

The Affordable Care Act is a federal law that is intended to increase access to insurance and stress preventing and wellness care. These types of plans help provide coverage to people who would otherwise be uninsured. These plans can be used by employers through private and public insurance plans. Plans under the Affordable Care Act are relatively strict with not much room for flexibility. It is also primarily geared towards those who are of low income and do not have any insurance. Plans such as Medicare are the plans provided under the rules of the Affordable Care Act.

 

KEY POINTS

• Guaranteed issue, cannot be turned down for coverage or charged more based on preexisting health conditions
• Tax credits and subsidies could help with your costs depending on how much you earn
• Plans cover a consistent set of ten essential health benefits, including preventive care, maternity care, and prescription coverage
• Enroll during annual open enrollment (November and December)

 

HOSPITAL AND DOCTOR FIXED INDEMNITY PLAN

A hospital and doctor fixed indemnity plan is usually used as a supplement to a primary medical insurance. It is not a typical health insurance plan in that you get paid the benefit when you get a certain service. For example, once you go to a covered hospital or receive a covered service, you receive a set amount of cash for that service, which would be considered the “benefit”. However, since this is not a primary medical insurance, it has to coincide with the primary major medical insurance plan, which could include network restrictions that could prevent this plan from operating properly. Ultimately, this plan is used as a secondary plan to supplement one’s major medical insurance. For a new group that is just establishing itself, it would be challenging to have a plan that coincides with this second plan. Following that, it does not provide much coverage. This type of plan would work best for young people who do not have any major medical issues, but it fails to take into account an aging population. Following that, it does not provide any coverage for preventive and wellness services.

 

KEY POINTS

• Pays predetermined amount of cash after you receive a specific medical service covered by plan
• Plans vary in what is covered, most don’t cover anything related to preexisting conditions
• Can apply any time, but must answer a series of questions to qualify
• Pays benefits regardless of other coverage
• Apply benefit payments towards your other health plan’s deductible
• Get cash to help meet prescription drug copays
• Help pay your share of lab or diagnostic costs, like for blood tests or X-rays
• Have money for unforeseen expenses surrounding a planned or unplanned surgery
• You get paid regardless of other insurance coverage
• Don’t have to meet a deductible before you receive benefits
• Not major medical insurance, does not provide the coverage mandate under ACA
• Does not provide coverage for all the essential health benefits outlined in the ACA
• Most likely not provide coverage for expenses resulting from preexisting conditions

 

CRITICAL ILLNESS INSURANCE/ACCIDENT INSURANCE

Critical illness insurance/accident insurance is a secondary type of medical insurance plan that supplements a primary insurance plan. This type of plan is used to help cover catastrophic illnesses/injuries that aids in covering the unexpected costs. It is not a major medical insurance, but it would be beneficial to have; especially for older populations that are more likely to qualify for injuries or illnesses that could require large costs. Following that, younger people choose to have this plan as it could be useful for unexpected accidents.

 

KEY POINTS

• Helps with the financial strain that comes with unexpected injury or illness
• Pays a lump sum cash benefit following diagnosis of a qualifying illness like cancer, stroke, or heart attack
• Accident insurance, also called personal accident insurance or supplemental accident insurance, helps pay medical costs from unexpected injuries

 

CRITICAL ILLNESS INSURANCE

• Tax advantaged
• Cash benefit
• Flexibility to allocate money as needed
• Simple allocation of questions with yes or no answers
• Various maximum lifetime benefit amounts from $10,000 to $50,000
• Covers heart attack, life-threatening cancer, loss of hearing, loss of speech, loss of vision, major organ transplant, paralysis, coma, renal failure, stroke, carcinoma in situ, coronary artery bypass graft
• Can use the cash benefit as you see fit
• Recommend to have enough cover to make mortgage payment for 2 years
• Can pair with other health insurance plans

 

ACCIDENT INSURANCE

• Pays benefits for accidental injuries
• Different options for the type of accident insurance: benefits paid directly to you, multiple benefit level so you can choose a monthly cost that works for you, no networks-choose where you want to get care, cash to help with unexpected medical costs due to accidental injury, cash for accidental injury medical costs that can help pay health insurance gaps, like a high deductible.

 

GROUP/COMPANY HEALTH INSURANCE PLANS

Group/company health insurance is employer-sponsored health insurance that is selected by the employer and offered to the employees. There are several types of group/company health insurance options outlined below. With policies like these, the employer splits the costs with the individual. However, there is less freedom in choosing the plan as the employer chooses all of the plan options. One benefit of having employer-sponsored health insurance is that contributions to the premium from the employer are not subject to federal taxes, and the employee’s contributions can be made before tax, which would lower one’s taxable income. There are several different types of plans that are available that each provide different types of coverages and flexibility.

 

FULLY-INSURED PLANS

In a fully-insured health plan, the employer pays a certain amount (premium) each month to the health insurance company. This premium is fixed for a year based on the number of employees enrolled in the plan each month. The health insurance company then covers the costs of the employees’ healthcare. This type of plan offers several challenges as the insurance company takes on risks when it comes to funding the healthcare costs of the employees. However, in cases like these the only cost the company is required to pay is the premium. Fully-Insured plans can be quicker to implement, but are pricier and allow for less control over benefit design. Fully-insured plans ultimately transfer the medical claims and day-to-day operations of the health plan to an insurance company.

 

KEY POINTS

• Insurance company taking on the risks involved with healthcare costs and charging your business an annual premium for the benefits in the insurance policy, which is partially paid for by employees
• Uses a variety of factors used to calculate group health insurance premiums including: size and health of the group, average age of the group, the employer’s claims history, types of occupation, level of coverage, and add-on benefits

 

SELF-FUNDED PLANS

A self-funded plan is typically considered the counterpart of a fully-insured plan. In a self-funded plan, the employer calculates the fixed costs and variable costs for the plan. Fixed costs include administrative fees, any stop-loss premiums, and any other set fees charged per employee. Variable costs could include payment of health care claims, which can vary month to month. Challenges with this plan include that it takes longer to implement as these plans go through third-party vendors to perform the operations associated with the self-funded plan. Large groups using self-insured plans can help these groups save a lot of money. In a self-funded plan, the savings come from the fact that self-insured plans have fewer benefit requirements, do not pay for an insurance company’s profit, and may be able to lower administration costs. Self-insured plans allow greater control over benefit design. Self-insured plans pay medical claims as they occur, which can improve cash flow. However, in a self-funded plan, the company takes on the risk of the paying of future medical claims. Self-insured plans do not have as much regulation compared to fully-insured plans, which would allow for more room for savings.

 

KEY POINTS

• Employer covers the employee health costs (difference between fully-insured and self-funded)
• Leads to more affordable rates and control over a plan, business runs the risk of having to pay for any catastrophic claims
  Often the option for large businesses
• Small businesses can opt for a partially self-funded plan with stop loss insurance, limits risk so that you can reap some of the benefits of self-funding without the entire burden in case any catastrophic claims occur

 

LEVEL-FUNDED PLANS

Level-funded health plans are considered a combination of self-funded plans and fully-insured plans. It combines the savings and customization of self-funding with the financial security of fully funded plans. In this type of plan employers can have contracts with insurance companies, but still take on more financial risk than a fully-insured plan. This type of plan is typically attractive amongst employers of small business groups as they allow for more savings, flexibility over the plan design, and fewer overhead expenses due to regulation. However, in level-funded plans, the carriers must spend at least 80% of the collected premium in order to avoid any excess premium charges.

 

KEY POINTS

• Based on monthly payment rate (not like most traditional plans)
• Use census info to determine the amount the small group should pay; info includes claims, allowances, fees, and stop-loss coverage premiums
• Carrier adjusts monthly level based on group performance

 

HEALTH MAINTENANCE ORGANIZATIONS (HMOS)

HMOs are health insurance policies with small networks. In an HMO, most care is primarily done in-network. If care is given out-of-network, extra bills are required. With an HMO there is less flexibility about who one can see. Typically, one must receive care from in-network and receiving out-of-network is not as common. By following in-network providers, costs are typically lower than most plans. Those in one geographic area would be partial to a HMO as they would not need as large of a network if they remain in the same region. It also tends to be on the cheaper side and is a good plan for people who are primarily healthy and do not have pressing medical needs.

 

KEY POINTS

• Delivers all health services through a network of healthcare providers and facilities
• Least freedom to choose your health care providers
• Least amount of paperwork compared to other plans
• Primary care doctor to manage your care and refer you to specialists when you need one
• Requires a referral before you can see a specialist
• Can see any doctor in HMO
• You pay a premium, deductible, and copay
• No claim forms

 

PREFERRED PROVIDER ORGANIZATIONS (PPOS)

A PPO is similar to a HMO with a couple of differences. PPOs tend to be more expensive than HMOs, but they do provide a larger network. PPOs also have a higher deductible than an HMO. PPOs are not as attractive to employers as they are more expensive and do not provide as much direct coverage over expenses. Instead, PPOs are primarily attractive for people who want a large network of providers, no requirements for referrals to see specialists, and more flexibility than other health insurance plans such as HMO.

 

KEY POINTS

• Moderate amount of freedom to choose your healthcare providers (more than HMO)
• No referral needed from primary care doctor to see a specialist
• Higher out-of-pocket costs if you see out-of-network doctors vs. in-network
• Can see any doctor in network of PPO, can see out-of-network too, but it will cost more
• You pay premium, deductible, copay, out-of-network doctor visits
• If you see an out-of-network provider you have to file a claim to get the PPO plan to pay you back and after they pay you back/their share, you will have to pay the rest

 

EXCLUSIVE PROVIDER ORGANIZATIONS (EPOS)

Exclusive Provider Organizations are managed care plans where services are only covered if you receive services in-network. Except for emergencies, all care should be provided in-network. In these types of plans, there is very little flexibility on who a person can see, as it can only be in-network. EPOs are considered a combination of a PPO and HMO, so people who would be attracted to this type of plan would be people who want the flexibility of a PPO with the cost savings of an HMO.

 

KEY POINTS

• Moderate amount of freedom (more than HMO), around same as PPO
• No coverage for out-of-network providers, will have to pay full cost
• Lower premium than PPO
• Can see any doctor in network of EPO, will not get coverage for any doctor outside of EPO
• You pay Premium, Deductible, Copay, full bill if you see out-of-network
• Little to no paperwork

 

POINT-OF-SERVICE (POS) PLANS

A point-of-service plan is a plan where you pay less if you use in-network providers. However, if one were to see a specialist, one would have to get a referral to see a specialist. With out-of-network providers, people who have POS plans will have to pay more unless the primary care in-network provider has given a referral. People who have POS plans are primarily people who are okay with having one primary care physician that coordinates their care for them.

 

KEY POINTS

• Blend of HMO with a PPO
• More freedom than HMO
• Moderate amount of paperwork if you see out-of-network doctor
• Primary care doctor who coordinates your care and refers you to specialists
• Can see in-network and out-of-network, will have to pay more for out-of-network
• You pay premium, deductible, and copays
• If you see an out-of-network doctor, you can file a claim to your POS plan to pay you back

 

HIGH-DEDUCTIBLE HEALTH PLANS (HDHPS)

A High Deductible Health Plan provides traditional medical coverage while providing flexibility and choice over how one can design the plan. HDHP plans do have higher deductibles and out-of-pocket maximums than traditional plans. This deductible must be met before coverage kicks in. HDHP plans also protect against catastrophic out-of-pocket expenses. There is a catastrophic maximum to be met before full coverage kicks in. If people are enrolled in a HDHP, they can also open a Health Savings Account (HSA). People who are able to open a HSA must be enrolled in a HDHP and not covered by another health plan. Ultimately, a HDHP allows flexibility with the same traditional coverage, but has higher out-of-pocket costs. People who are generally healthy with no serious medical expenses would potentially save money by having a HDHP.

 

KEY POINTS

• Can be a HMO, PPO, EPO, or POS
• Higher out-of-pocket costs than many types of plans, if you reach max out-of-pocket amount, they will pay 100% of your care
• Health savings account to help pay for your care, money put into HSA can be used tax free on eligible medical expenses, to have HSA must be enrolled in HDHP, max you can put into HSA is 3550-individual 7100-families
• Doctors you can see depends on your plan
• Lower premium compared to other plans
• Deductible 1400 but not more than 6900-individual, 2800 but not more than 13800-family
• Free preventative care even if you have not met deductible
• Keep all medical receipts

 

CATASTROPHIC PLANS

Catastrophic health plans have low monthly premiums and high deductibles. These plans do not offer much coverage, but are good plans to have in the case of serious illnesses and injuries. With these types of plans, most routine medical expenses are not covered. These types of plans are common among young people who do not need as much coverage for medical expenses, but want a safety net in case something serious happens. People who cannot afford a full plan and are young with no pressing medical needs might choose to have catastrophic plans. People of old age with extenuating circumstances may also qualify to have a catastrophic plan.

 

KEY POINTS

• Typically for people under the age of 30
• Lower premium, higher deductible
• 3 primary care visits before the deductible applies
• Free preventative care, even if you have not met the deductible
• Can see any doctor on plan’s network, individual plans might have additional rules with specialists
• You pay premium and deductible ($8,150-individual $16,300-family) after you reach deductible, plan will pay 100% of your medical costs for covered benefits
• Keep track of your medical expenses to show you have met the deductible

 

UNDERSTANDING AN HMO VS PPO

Based on the overview of group insurance plans above, a majority of the plans, besides the HMO and PPO, are a combination of these two plans. It is worth noting their differences, in order to get a clearer picture of what each plan offers and how hybrid plans (EPO and POS) blend the characteristics of each plan. Each plan comes with its own benefits and drawbacks, but it is ultimately up to the patient/consumer to decide which plan will fit his or her needs best.

 

HMO

An HMO (Health Maintenance Organization), as described above, is a type of group insurance plan that has several characteristics outlined below.

 

KEY POINTS

The HMO plans analyzed in this project were:

UnitedHealthcare Bronze HMO A, UnitedHealthcare Bronze HMO B Kaiser Permanente Bronze 60 HDHP HMO 7000/0%, Molina Bronze 60 HMO, BCBS HMO Facility, Anthem Silver HMO C, Anthem Silver HMO D

• Delivers all health services through a network of healthcare providers and facilities
• Least freedom to choose your health care providers
• Least amount of paperwork compared to other plans
• Primary care doctor to manage your care and refer you to specialists when you need one
• Requires a referral before you can see a specialist
• Can see any doctor in HMO
• You pay a premium, deductible, and copay
• No claim forms

 

PPO

A PPO (Preferred Provider Organization), as described above, is a common plan also provided by employers. It does have several differences from an HMO that are outlined below.

 

KEY POINTS

The PPO plans analyzed in this project were:

Cigna Life Insurance Bronze 60 PPO, Molina Minimum Coverage Plan (8150), Cigna Health and Life Insurance, Cigna Connect (6500)

• Moderate amount of freedom to choose your healthcare providers (more than HMO)
• No referral needed from primary care doctor to see a specialist
• Higher out-of-pocket costs if you see out-of-network doctors vs. in-network
• Can see any doctor in network of PPO, can see out-of-network too, but it will cost more
• You pay premium, deductible, copay, out-of-network doctor visits
• If you see an out-of-network provider you have to file a claim to get the PPO plan to pay you back and after they pay you back/their share, you will have to pay the rest

 

THE DRIVERS THAT INCREASE INSURANCE PREMIUMS

Now that we understand the different insurance types, let’s explore the things that increase insurance premiums. The inclusion or lack of these within your population to be insured are important because they affect the pricing of your health insurance policy. Generally, premiums are higher when the people on the plan have health risks that would require more care and usage of services. For a population that is generally healthy with a small amount having issues that could potentially increase premiums, there are several options one could follow to help address the issues of the entire population. In cases like these, sticking to general plans would be a good option as they are not as geared towards one specific population and are good at encompassing a large population with a diverse set of medical needs. Another option would be to have a plan such as a High Deductible Health Plan combined with a Catastrophic Plan as it allows for more flexibility and control over the design of the plan.

Social health insurance schemes are the major drivers behind unsustainable fiscal policies

• Population aging: significant factor, chronic diseases require frequent spending
• More people are qualifying for Medicare and Medicaid
• More money will be spent on health care for more people as the population gets older and sicker
• Disease prevalence/incidence
• Service utilizations
• Service price and intensity: As technology increased and medications became more advanced, healthcare services became more expensive
• Healthcare Finance and Delivery: the fee-for-service reimbursement: generates a strong incentive to perform many tests and services (to get paid more)
• Fragmentation of care delivery: providers get paid more for volume rather than patient outcomes (decreases incentive to deliver efficient care)
• Administrative burden: increased paperwork, which means nore administrative resources, which raises both provider and payer costs
• Insurance design: employer-sponsored health insurance tax exclusion encourages increasingly generous benefit designs and represents a significant loss in revenue for the federal government, utilization and prevention-access to health care services with little cost-sharing encourages higher care utilization and leads to increased spending
• Limited consensus on standards of care cost and quality, customers are not allowed to make fair and open comparisons of care to make cost-effective choices
• Insurers gaining market share across the nations means they could use this power to negotiate lower provider reimbursement
• Recent and pending policy changes–>CSR subsidies must be offered to lower-income enrollees, but insurance companies are no longer reimbursed so insurers raised the price of premiums
• Elimination of the individual mandate financial penalty: encouraged health people to enroll, but as it was eliminated healthy individuals forgo coverage so premiums increased as less people were enrolling
• If you are healthy, your premium would be far more than what it would actually cost you to get health care over the course of a year
• If you are a bit older your premium will probably be around the same cost as what you would have paid out of pocket
• If you are sick, then the insurance premiums might be a bang for your buck

the health plan proposal and tutorial covering rationale for best option: cost analysis, savings analysis compared to other options, coverage comparisons?

 

MAJOR US INSURANCE PROVIDERS

Next we researched all the major insurance providers and the various plans they offered. Our goal was to determine what each company is known for and what unique features they provide. We also determined who these companies aim to serve and how. Based on the preferences of our organizations and the features of each company, we chose several plans from each company that best fit the population of these organizations. After determining several plans from each company, we analyzed the features of each plan. Our goal was to analyze plans that best fit the vision for the organization (high deductible and took into account an aging population). After this, these plans were then compared amongst the different companies and narrowed down even more. Once a set of several final plans were chosen from the different companies, these were then ranked using a numbering system with higher points given for good benefits and lower points for costs. Higher points were given with plans for higher deductibles and coverages that had low out-of-pocket expenses. Ultimately, using this point system the plan with the highest point was determined to be the plan of choosing.

Here are the major insurance providers we researched:

1. Molina Healthcare
2. UnitedHealth Group
3. Kaiser Foundation
4. Anthem
5. Humana
6. Aetna
7. Blue Cross Blue Shield
8. Centene Corp.
9. Cigna
10. National General

Here is the summary of what they offer and how we ranked them. Click the image for the source Google Spreadsheet.

 

MOLINA EXAMPLE

This is an example of one of the companies we analyzed: Molina Healthcare. The rest of the companies have a similar breakdown outlined in the spreadsheet above. Molina’s healthcare plan is known for providing quality healthcare geared towards low-income populations. Several plans of note are outlined below and include a range of HMOs, PPOs, and one minimum coverage plan. Overall, the HMO and PPOs offer the same types of coverage with differences primarily being the fundamental differences being HMO and PPO (outlined above). The minimum coverage plan has a high deductible and no copays for any service offered, but this type of plan is geared towards young people who do not need coverage or routine care.

 

KEY POINTS

• Primarily serves low-income populations
• Emphasizes providing wellness offerings alongside healthcare services
• Not good for companies (primarily good for families and individual customers)

8 Possible plans:

 

COMPARISON BY SPECIFIC OFFERING*

• Comparison by Deductible
• Comparison by Out-of-Pocket Limit
• Comparison by Primary Care Visit
• Comparison by Specialist Visit
• Comparison by Preventive Care/screening/immunization
• Comparison by Diagnostic Test
• Comparison by Imaging
• Comparison by Pharmacy Tier 1
• Comparison by Pharmacy Tier 2
• Comparison by Pharmacy Tier 3
• Comparison by Pharmacy Tier 4
• Comparison by Preferred Generic Drugs
• Comparison by Preferred Brand Drugs
• Comparison by Non-Preferred generic/brand drugs
• Comparison by Preferred Speciality Drugs
• Comparison by Preferred Outpatient Surgery
• Comparison by Preferred Physician/Surgeon
• Comparison by Preferred Emergency Room Care
• Comparison by Preferred Emergency Medical Transportation
• Comparison by Urgent Care
• Comparison by Facility Fee
• Comparison by Preferred Outpatient services (mental health)
• Comparison by Preferred Inpatient services (mental health)
• Comparison by Office visits primary care (pregnancy)
• Comparison by Office visit specialist (pregnancy)
• Comparison by Childbirth/delivery professional services
• Comparison by Childbirth/delivery facility services
• Comparison by Home health care
• Comparison by Rehabilitation services
• Comparison by Habilitation services
• Comparison by Skilled nursing care
• Comparison by Durable medical equipment (DME)
• Comparison by Hospice services
• Comparison by Children’s eye exams
• Comparison by Children’s glasses
• Comparison by Children’s dental check up

Once several insurance plans were chosen, the different plan options were compared against each other based on what each coverage was and how much it cost. Since having a high deductible was an important goal in finding an appropriate plan, the comparison by deductible was one of the first items that was addressed. Following that, out-of-pocket limits were also important as they were a good indicator of how much coverage each plan offers. After that, each type of coverage was included and its costs were ranked from highest copay/coinsurance to lowest copay/coinsurance. By doing this, we were able to see how each plan organized its different benefits and associated costs. Based on an individual’s health needs, he or she would need different coverages that provide lower costs for certain services and some services that would not need any coverage. The goal of this organization was to target a young population while taking into account an aging population as well as preventive services. Therefore, when deciding how to compare the different plans, services that covered more of these coverages were given a higher ranking. Add intro paragraph… Talk about how different health situations and desires may change what people consider their top priority, so here’s an analysis or each option.

* The information presented below has been summarized in the spreadsheet linked above. The information gives a breakdown based on each coverage portion while the information in the spreadsheet gives a more holistic comparison across all plans.

Copay: A fixed out-of-pocket amount paid by the insured for covered services

Coinsurance: A type of insurance in which the insured pays a part of the claim. Ex.80% coinsurance=insurance company is responsible for 80% and you are responsible for 20% plus deductible.

 

COMPARISON BY DEDUCTIBLE (HIGHEST TO LOWEST)

Having a low or high deductible entirely depends on the type of coverage you want out of your health insurance policy. Plans with high deductible will have higher out-of-pocket costs, but they still save consumers money. This is generally because monthly premiums are lower compared to plans with low deductibles, which ends up being more cost effective in the long run. However, with high-deductible plans, many consumers tend to not get as many services. Plans that offer lower deductibles have more predictable costs and more generous coverage, but they often have higher premiums that can be hard to fit on a monthly budget. Plans that have high deductibles will also have out-of-pocket limits close to the same amount. A plan with a high deductible is best for people who are healthy and rarely get sick and people who are able to pay. Following that, if one were to have a plan that has a high deductible, they could also be eligible to open a health savings account (HSA), which is a tax-advantage and is a way to save or invest money. Low deductible health plans make it easier to predict medical expenses, but have higher premiums. Low deductible health plans are best suited for people who are pregnant, planning to become pregnant, or have small children. It is also useful for people who have a chronic condition that needs frequent medical attention. A low deductible health plan would also be helpful for people who are considering reparative surgery, taking several prescription medications, or playing sports that could have a high risk of injury.

 

KEY POINTS

Deductible: The amount you pay for covered health care services before your insurance plan starts to pay.

1. Molina Minimum Coverage Plan (8150)
2. UnitedHealthcare Bronze HMO A (7200)
3. Kaiser Permanente Bronze 60 HDHP HMO 7000/0% (7000)
4. UnitedHealthcare Bronze HMO B (6900)
5. Cigna Health and Life Insurance, Cigna Connect (6500)
6. Molina Bronze 60 HMO + Cigna Life Insurance Bronze 60 PPO (6,300)
7. BCBS HMO Facility (5800)
8. Anthem Silver HMO D (2,250)
9. Anthem Silver HMO C (2,250)

 

COMPARISON BY OUT-OF-POCKET LIMIT (HIGHEST TO LOWEST)

An out-of-pocket limit is how much money you must pay before your plan covers 100% of the costs. This money is spent on deductibles, copays, and coinsurance. However, this out-of-pocket plan does not cover out-of-network care, monthly premiums, and costs above the allowed amount that a service may charge. Having a lower out-of-pocket limit allows you to spend less on insurance, but it means that the monthly premiums will be higher. Plans that have low premiums tend to have high out-of-pocket limits and deductibles. Specifically for healthy people, plans with high deductibles and out-of-pocket limits also tend to be more cost effective as this population does not require as much medical attention.

 

KEY POINTS

Out-of-Pocket Limit: The most you have to pay for covered services in a plan year. After you spend this amount on deductibles, copayments, and coinsurance for in-network care and services your health plays 100% of the costs of covered benefits.

1. Cigna Health and Life Insurance, Cigna Connect 6500 + Molina Minimum Coverage Plan + UnitedHealthcare Bronze HMO A (8150)
2. Anthem Silver HMO C + Anthem Silver HMO D (7900)
3. Cigna Life Insurance Bronze 60 PPO + Molina Bronze 60 HMO (7800)
4. BCBS HMO Facility Deductible 40-40%/5800 + Kaiser Permanente Bronze 60 HDHP HMO 7000/0% (7000)
5. UnitedHealthcare Bronze HMO B (6900)

 

COMPARISON BY PRIMARY CARE VISIT (HIGHEST TO LOWEST)*

The primary care visit is where most patients will get services from. These are the providers that are a significant point of contact for patients/consumers. Plans that have higher copays or coinsurance indicate that it would have higher costs in person, but could be part of plans that have lower premiums, which would end up being more cost effective.

*As a special note for this section as well as the sections that will be listed below: Plans that have higher copays/coinsurance relate to plans that have lower monthly premiums (which also means a higher deductible). These types of plans tend to be more cost effective for people who do not have serious medical expenses. However, plans with lower copays/coinsurance are less expensive, but tend to be part of plans that have higher monthly premiums. To determine what type of setup works best, one must analyze his or her healthcare needs first.

 

KEY POINTS

Primary Care Visit: Healthcare for day-to-day issues. Usually the first point of contact and principal point of continuing care for patients within a healthcare system.

COPAY:

1. Cigna Life Insurance Bronze 60 PPO + Molina Bronze 60 HMO (65)
2. Anthem Silver HMO D (50)
3. BCBS HMO Facility Deductible 40-40%/5800 (40)

COINSURANCE:

1. Cigna Health and Life Insurance, Cigna Connect 6500 (50%)
2. UnitedHealthcare Bronze HMO A (40%)
3. Anthem Silver HMO C (70% by deductible 30% coinsurance)

NO CHARGE/0% COINSURANCE:

1. Molina Minimum Coverage Plan
2. UnitedHealthcare Bronze HMO B
3. Kaiser Permanente Bronze 60 HDHP HMO 7000/0%

 

COMPARISON BY SPECIALIST VISIT (HIGHEST TO LOWEST)

A visit to the specialist is usually done after a visit from a primary care provider. As mentioned above, comparing this type of coverage is important as it highlights flexibility when it comes to seeing a specialist. Many plans require coordination with a primary care provider to have access to a specialist and it can sometimes cost more money to go see one.

 

KEY POINTS

Specialist Visit: Health care provided by specialty doctors for a specific area of medicine-usually referred to a specialist from a primary care provider.

COPAY:

1. Cigna Life Insurance Bronze 60 PPO + Molina Bronze 60 HMO (95)
2. Anthem Silver HMO D (75)

COINSURANCE:

1. Cigna Health and LIfe Insurance, Cigna Connect 6500 (50%)
2. UnitedHealthcare Bronze HMO A (40%)
3. Anthem Silver HMO C (70% by deductible 30% coinsurance)

NO CHARGE/0% COINSURANCE:

1. Molina Minimum Coverage Plan
2. UnitedHealthcare Bronze HMO B
3. Kaiser Permanente Bronze 60 HDHP HMO 7000/0%

N/A:

1. BCBS HMO Facility Deductible 40-40%/5800

 

COMPARISON BY PREVENTIVE CARE (HIGHEST TO LOWEST)

As one of our goals for our health insurance plan was to have preventive care provided in our plan, this was an important benefit to highlight. However, in general most plans cover preventive care/screening/immunizations at no cost to the patient.

 

KEY POINTS

Preventive Care: Care you receive to prevent illnesses or diseases.

All no charge or N/A.

 

COMPARISON BY DIAGNOSTIC TEST (HIGHEST TO LOWEST)

Diagnostic Tests are also important in preventive care and are needed to determine whether or not an individual may need to see a specialist.

 

KEY POINTS

Diagnostic Test: An examination to identify an individual’s specific areas of weakness and strength. It used to determine a condition, disease, or illness.

COPAY:

1. Cigna Life Insurance Bronze 60 PPO ($40)

COINSURANCE:

1. Cigna Health and LIfe Insurance,Cigna Connect 6500 (50%)
2. Molina Bronze 60 HMO + UnitedHealthcare Bronze HMO A (40%)

NO CHARGE/0% COINSURANCE:

1. Molina Minimum Coverage Plan
2. UnitedHealthcare Bronze HMO B
3. Kaiser Permanente Bronze 60 HDHP HMO 7000/0%

N/A:

1. Anthem Silver HMO C
2. Anthem Silver HMO D
3. BCBS HMO Facility Deductible 40-40%/5800

 

COMPARISON BY IMAGING (HIGHEST TO LOWEST)

Imaging, which has the same ultimate goal as Diagnostic Tests, is also crucial to preventive care and is needed to determine whether an individual must see a specialist.

 

KEY POINTS

Imaging: Techniques and processes used to create images of various parts of the human body for diagnostic and treatment purposes (X-ray, MRI, etc.)

COPAY:

1. Anthem Silver HMO D ($40)

COINSURANCE:

1. Cigna Health and Life Insurance, Cigna Connect 6500 (50% coinsurance)
2. Cigna Life Insurance Bronze 60 PPO + Molina Bronze 60 HMO + UnitedHealthcare Bronze HMO A (40%)
3. Anthem Silver HMO C (70% deductible 30% coinsurance)

NO CHARGE/0% COINSURANCE:

1. Molina Minimum Coverage Plan
2. UnitedHealthcare Bronze HMO B
3. Kaiser Permanente Bronze 60 HDHP HMO 70000/0%
4. BCBS HMO Facility Deductible 40-40%/5800

 

COMPARISON BY PHARMACY TIER 1 (HIGHEST TO LOWEST)

Pharmacy Tier 1 drugs contain the preferred generic drugs. Access to drugs and medicine is a crucial part of one’s health insurance plan, so ranking the plans by how much they cost for each pharmacy tier can provide several significant insights into the quality of the health insurance plan.

 

KEY POINTS

Tier 1: Preferred generic drugs. Commonly prescribed generic drugs.

**Cigna does not follow same setup

1. Molina Bronze 60 HMO ($80 copay, $160 mail order)
2. UnitedHealthcare Bronze HMO A + Anthem Silver HMO C($20 copay, $40 mail order)
3. BCBS HMO Facility Deductible 40-40%/5800 ($10/prescription, mail order:$20/prescription)

COINSURANCE:

1. Anthem Silver HMO D (60% deductible 40% coinsurance)

NO CHARGE/0% COINSURANCE:

1. Molina Minimum Coverage Plan
2. UnitedHealthcare Bronze HMO B
3. Kaiser Permanente Bronze 60 HDHP HMO 7000/0%

 

COMPARISON BY PHARMACY TIER 2 (HIGHEST TO LOWEST)

Pharmacy Tier 2 still contains generic drugs, but these generic drugs tend to be on the pricier side than Tier 1 drugs.

 

KEY POINTS

Tier 2-Generic drugs: cost a little bit more than Tier 1 drugs.

COPAY:

1. Anthem Silver HMO C ($250 copay)
2. UnitedHealthcare Bronze HMO A ($50 retail, $100 mail order)
3. BCBS HMO Facility Deductible 40-40%/5800 ($25 retail, $80 mail order)

COINSURANCE:

1. Anthem Silver HMO D (60% deductible 40% coinsurance)
2. Molina Bronze 60 HMO (40% retail , 26.67% mail order)

NO CHARGE/ 0% COINSURANCE:

1. Molina Minimum Coverage Plan
2. UnitedHealthcare Bronze HMO B
3. Kaiser Permanente Bronze 60 HDHP HMO 7000/0%

 

COMPARISON BY PHARMACY TIER 3 (HIGHEST TO LOWEST)

Pharmacy Tier 3 Drugs are the preferred brand name drugs, but are still on the lower end when it comes to cost.

 

KEY POINTS

Tier 3-Preferred brand drugs: Brand name drugs that do not have a generic equivalent drug. The lowest cost brand name drugs.

COPAY:

1. Anthem Silver HMO C ($250 copay)
2. UnitedHealthcare Bronze HMO A ($100 retail, $200 mail order)
3. BCBS HMO Facility Deductible 40-40%/5800 ($40 retail, $80 mail order)
4. Anthem Silver HMO D ($20 copay)

COINSURANCE:

1. Molina Bronze 60 HMO (40% coinsurance, 26.67% mail order)

NO CHARGE/0% COINSURANCE:

1. Molina Minimum Coverage Plan
2. UnitedHealthcare Bronze HMO B
3. Kaiser Permanente Bronze 60 HDHP HMO 7000/0%

 

COMPARISON BY PHARMACY TIER 4 (HIGHEST TO LOWEST)

Pharmacy Tier 4 drugs would be brand name drugs that are on the pricier side, and they tend not to be a preferred drug. This tier also includes generic drugs that are not included in any of the other tiers.

 

KEY POINTS

Tier 4-Non preferred drug: Higher priced brand name and generic drugs that are not in a preferred tier.

COINSURANCE:

1. Molina Bronze 60 HMO (40% coinsurance, mail order not covered)
2. UnitedHealthcare Bronze HMO A (40% retail 40% mail order)
3. BCBS HMO Facility Deductible 40-40%/5800 (retail: 20% coinsurance up to $200 prescription mail order: 20% coinsurance up to $400/prescription)

NO CHARGE:

1. Molina Minimum Coverage Plan
2. UnitedHealthcare Bronze HMO B
3. Kaiser Permanente Bronze 60 HDHP HMO 7000/0%

N/A:

1. Anthem Silver HMO C
2. Anthem Silver HMO D

 

COMPARISON BY PREFERRED GENERIC DRUGS

Preferred generic drugs are the same as Tier 1, but the Cigna Health Insurance plans classify their prescription drug rates according to this model, which is essentially the same as the Tiers structure with different names.

 

KEY POINTS

Preferred Generic Drugs: Equivalent to Tier 1

**Only Cigna follows this set up

COPAY:

1. Cigna Life Insurance Bronze 60 PPO ($18 retail, $36 mail order)

COINSURANCE:

1. Cigna Health and Life Insurance, Cigna Connect 6500 (50% coinsurance)

 

COMPARISON BY PREFERRED BRAND DRUGS

Preferred Brand Drugs are considered to be the same as Tier 3 drugs.

 

KEY POINTS

Preferred Brand Drugs: Equivalent to Tier 3

**Only Cigna follows this set up

1. Cigna Health and Life Insurance, Cigna Connect 6500 (50% coinsurance)
2. Cigna Life Insurance Bronze 60 PPO (40% coinsurance)

 

COMPARISON BY NON-PREFERRED GENERIC DRUGS

Non-Preferred generic and brand name drugs are considered to be the same as Tier 4 drugs.

 

KEY POINTS

Non-Preferred generic/brand drugs: Equivalent to to Tier 4

**Only Cigna follows this set up

1. Cigna Health and Life Insurance, Cigna Connect 6500 (50% coinsurance)
2. Cigna Life Insurance Bronze 60 PPO (40% coinsurance)

 

COMPARISON BY PREFERRED SPECIALITY DRUGS

Specialty Drugs are considered to be Tier 5 drugs. It is rare to have drugs in this tier/group, which is why coverage for this type of medicine is not really mentioned. These types of drugs are the most expensive and are used to treat the most complex conditions.

 

KEY POINTS

Speciality Drugs: Tier 5 Drugs. Most expensive drugs. Used to treat complex conditions, can be generic or brand name.

**Only Cigna follows this set up

1. Cigna Health and Life Insurance, Cigna Connect 6500 (50% coinsurance)
2. Cigna Life Insurance Bronze 60 PPO (40% coinsurance)

 

COMPARISON BY PREFERRED OUTPATIENT SURGERY

While there is not much information on a plan’s coverage of outpatient surgery, it is worth noting what each plan offers, if there is information given.

 

KEY POINTS

Outpatient Surgery: Surgery and discharge done the same day and no overnight stay is required.

COINSURANCE:

1. Molina Bronze 60 HMO (40% coinsurance)
2. Molina Minimum Coverage Plan (0% coinsurance)

N/A:

1. UnitedHealthcare Bronze HMO A
2. UnitedHealthcare Bronze HMO B
3. Kaiser Permanente Bronze 60 HDHP HMO 7000/0%
4. Anthem Silver HMO C
5. Anthem Silver HMO D
6. BCBS HMO Facility Deductible 40-40%/5800
7. Cigna Life Insurance Bronze 60 PPO
8. Cigna Health and Life Insurance, Cigna Connect 6500

 

COMPARISON BY PREFERRED PHYSICIAN

Physician/Surgeon fees can easily become very expensive, and the right healthcare plan should be able to minimize the cost on the patient.

KEY POINTS

Physician/Surgeon: Cost of having a physician/surgeon+their services

COPAY:

1. Anthem Silver HMO D

COINSURANCE:

1. Molina Bronze 60 HMO + UnitedHealthcare Bronze HMO A (40% coinsurance)
2. Anthem Silver HMO C (70% deductible 30% coinsurance)

NO CHARGE:

1. BCBS HMO Facility Deductible 40-40%/5800
2. UnitedHealthcare Bronze HMO B
3. Molina Minimum Coverage Plan

N/A:

1. Cigna LIfe Insurance Bronze 60 PPO
2. Cigna Health and Life Insurance, Cigna Connect 6500
3. Kaiser Permanente Bronze 60 HDHP HMO 7000/0%

 

COMPARISON BY EMERGENCY ROOM CARE

Emergency Room Care is a typical benefit in most health insurance plans, but coverage can vary depending on the plan, which is why the costs have been outlined below.

 

KEY POINTS

Emergency Room: All services provided when a patient visits an emergency room for an emergency condition.

COPAY:

1. BCBS HMO Facility Deductible 40-40%/5800 (facility fee:$350, physician fee: No charge)
2. Anthem Silver HMO D ($200)

COINSURANCE:

1. Cigna Health and LIfe Insurance, Cigna Connect 6500 (50%)
2. Molina Bronze 60 HMO+UnitedHealthcare Bronze HMO A+Cigna LIfe Insurance Bronze 60 PPO (40%)
3. Anthem SIlver HMO C (70% deductible 30% coinsurance)

NO CHARGE:

1. Molina MInimum Coverage Plan
2. UnitedHealthcare Bronze HMO B
3. Kaiser Permanente Bronze 60 HDHP HMO 7000/0%

 

COMPARISON BY EMERGENCY MEDICAL TRANSPORTATION

Emergency Medical Transportation is also an important part that is paired with emergency room care with varying costs depending on the type of health insurance.

 

KEY POINTS

Emergency Medical Transportation: Cost to transport patients to the emergency room.

COPAY:

1. BCBS HMO Facility Deductible 40-40%/5800 ($40)

COINSURANCE:

1. Cigna Health and LIfe Insurance (50%)
2. Molina Bronze 60 HMO + UnitedHealthcare Bronze HMO A+Cigna LIfe Insurance Bronze 60 PPO (40%)
3. Anthem Silver HMO D (60% deductible 40% coinsurance)
4. Anthem Silver HMO C (70% deductible 30% coinsurance)

NO CHARGE:

1. Molina Minimum Coverage Plan
2. UnitedHealthcare Bronze HMO B
3. Kaiser Permanente Bronze 60 HDHP HMO 7000/0%

 

COMPARISON BY URGENT CARE

Urgent Care is an important benefit to have on any health insurance plan. While most insurance plans cover urgent care based on coinsurance, some require copays, which can lead to different cost savings in the long run. Since copays are a set rate whereas coinsurances are a percentage of the total costs, the cost for urgent care may be different depending on the type of care received and which plan one has.

 

KEY POINTS

Urgent care: Diagnosis and treatment of medical conditions, which are serious or acute but post no immediate threat to life and health but require medical attention within 24 hours. Different from an emergency room as it relates to less serious health problems.

COPAY:

1. Molina Bronze 60 HMO + Cigna LIfe Insurance Bronze 60 PPO ($65)
2. BCBS HMO Facility Deductible 40-40%/5800 ($40)

COINSURANCE:

1. Cigna Health and Life Insurance, Cigna Connect 6500 (50% coinsurance)
2. UnitedHealthcare Bronze HMO A (40%)
3. Anthem SIlver HMO C (70% deductible 30% coinsurance)
4. Anthem SIlver HMO D (60% deductible 40% coinsurance)

NO CHARGE:

1. Molina Minimum Coverage Plan
2. UnitedHealthcare Bronze HMO B
3. Kaiser Permanente Bronze 60 HDHP HMO 7000/0%

 

COMPARISON BY FACILITY FEE

This Fee is a typical benefit that should be provided in health insurance plans. It should be a typical benefit that is covered in plans.

 

KEY POINTS

Facility Fee: Charge you have to pay when you see a doctor that is not owned by that doctor.

COINSURANCE:

1. Cigna Health and Life Insurance, Cigna Connect 6500 (50%)
2. Molina Bronze 60 HMO + UnitedHealthcare Bronze HMO A +Cigna LIfe Insurance Bronze 60 PPO (40%)
3. Anthem Silver HMO D (60% deductible 40% coinsurance)
4. Anthem Silver HMO C (70% deductible 30% coinsurance)
5. BCBS HMO Facility Deductible 40-40%/5800 (ASC:30% coinsurance Outpatient: 40%)

NO CHARGE:

1. Molina Minimum Coverage Plan
2. UnitedHealthcare Bronze HMO B
3. Kaiser Permanente Bronze 60 HDHP HMO 7000/0%

 

COMPARISON BY OUTPATIENT SERVICES (MENTAL HEALTH)

Outpatient services are an important benefit in healthcare plans, and each plan outlined has different statements regarding their associated cost as outlined below.

 

KEY POINTS

Outpatient Services: A term referring to the services of a patient who receives care at a medical facility but who is not admitted to the facility overnight, or for 24 hours or less.

COPAY:

1. Molina Bronze 60 HMO ($65)
2. BCBS HMO Facility Deductible 40-40%/5800 (Office visit:$40/visit)

COINSURANCE:

1. Cigna Health and LIfe Insurance, Cigna Connect 6500 (50%)
2. UnitedHealthcare Bronze HMO A + Cigna LIfe Insurance Bronze 60 PPO (40%)
3. Anthem Silver HMO C (70% deductible 30% coinsurance)
4. Anthem Silver HMO D (70% deductible 30% coinsurance)

NO CHARGE:

1. Molina Minimum Coverage Plan
2. UnitedHealthcare Bronze HMO B
3. Kaiser Permanente Bronze 60 HDHP HMO 7000/0%

 

COMPARISON BY INPATIENT SERVICES (MENTAL HEALTH)

Inpatient services, which also includes mental health services, carry the same importance as outpatient health. It is important to note how different plans require different types of costs for these benefits as well as the other benefits being described.

 

KEY POINTS

Inpatient Services: The services of a patient who has been admitted to a hospital for at least 24 hours.

COPAY:

1. Cigna Life Insurance Bronze 60 PPO ($65)

COINSURANCE:

1. Cigna Health and Life Insurance, Cigna Connect 6500 (50%)
2. Molina Bronze 60 HMO + UnitedHealthcare Bronze HMO A+ BCBS HMO Facility Deductible (40%)
3. Anthem Silver HMO C (70% deductible 30% coinsurance)

NO CHARGE:

1. Molina Minimum Coverage Plan
2. UnitedHealthcare Bronze HMO B
3. Kaiser Permanente Bronze 60 HDHP HMO 7000/0%
4. Anthem Silver HMO D (100% deductible)

 

COMPARISON BY OFFICE VISITS PRIMARY CARE

For pregnant women, office visits require more care than the regular office visit mentioned in the beginning. Therefore, these costs will be different, but are still worth highlighting.

 

KEY POINTS

Office visit Primary care: The amount you pay when you go to the office to receive routine care from your primary care provider for pregnancy.

COPAY:

1. Molina Bronze 60 HMO ($65)

COINSURANCE:

1. Cigna Health and Life Insurance, Cigna Connect 6500 (50%)
2. Cigna Life Insurance Bronze 60 PPO (40%)

NO CHARGE:

1. Molina Minimum Coverage Plan
2. Anthem SIlver HMO C (Covered as illness)
3. Anthem Silver HMO D (Applicable by Deductible)
4. BCBS HMO Facility Deductible 40-40%/5800
5. UnitedHealthcare Bronze HMO A
6. UnitedHealthcare Bronze HMO B
7. Kaiser Permanente Bronze 60 HDHP HMO 7000/0%

 

COMPARISON BY OFFICE VISIT SPECIALIST

Similar to the office visits mentioned above, seeing specialists for pregnancy issues will require different costs and coverage by the health insurance plan as outlined below.

 

KEY POINTS

Office visit Specialist care: The amount you pay when you go to office to receive care from some type of pregnancy specialist.

COPAY:

1. Anthem Silver HMO C ($250)
2. Anthem Silver HMO D ($250)
3. Molina Bronze 60 HMO ($95)

NO CHARGE:

1. Molina Minimum Coverage Plan

N/A:

1. UnitedHealthcare Bronze HMO A
2. UnitedHealthcare Bronze HMO B
3. Kaiser Permanente Bronze 60 HDHP HMO 7000/0%
4. BCBS HMO Facility Deductible 40-40%/5800
5. Cigna Life Insurance Bronze 60 PPO
6. Cigna Health and Life Insurance, Cigna Connect 6500

 

COMPARISON BY CHILDBIRTH/DELIVERY PROFESSIONAL SERVICES

As this community is aimed towards a young population, childbirth is an important benefit to consider. Since the pregnancy coverages were included in this analysis, it was necessary to also include the childbirth services in order to get a full picture.

 

KEY POINTS

Childbirth/delivery professional services: Services provided by a professional for a patient undergoing childbirth.

COINSURANCE:

1. Cigna Health and Life Insurance, Cigna Connect (50%)
2. Molina Bronze 60 HMO + UnitedHealthcare Bronze HMO A(40%)

NO CHARGE:

1. Molina Minimum Coverage Plan
2. UnitedHealthcare Bronze HMO B
3. Anthem Silver HMO C (Covered as illness)
4. Anthem Silver HMO D (Applicable by deductible)
5. BCBS HMO Facility Deductible 40-40%/5800
6. Childbirth/delivery professional services

N/A:

1. Kaiser Permanente Bronze 60 HDHP HMO 7000/0%

 

 

COMPARISON BY CHILDBIRTH/DELIVERY FACILITY SERVICES

Depending on whether or not the patient decides to give birth in a certain facility, there are also costs associated with using that facility, which are outlined below.

 

KEY POINTS

1. Childbirth/delivery facility services: The price for the facility used during the childbirth/delivery procedure.

COINSURANCE:

1. Cigna Health and Life Insurance, Cigna Connect 6500 (50%)
2. Molina Bronze 60 HMO + UnitedHealthcare Bronze HMO A + BCBS HMO Facility Deductible + Cigna LIfe Insurance
3. Bronze 60 PPO (40%)

NO CHARGE:

1. Molina Minimum Coverage Plan
2. UnitedHealthcare Bronze HMO B

N/A:

1. Kaiser Permanente Bronze 60 HDHP HMO 7000/0%
2. Anthem Silver HMO C
3. Anthem Silver HMO D

 

COMPARISON BY HOME HEALTH CARE

Home health care is primarily for older citizens, but it can also be for patients that require care at home under extenuating circumstances. The costs denoted by each plan are outlined below.

 

KEY POINTS

Home health care: Part-time care that is provided by medical professionals in the home setting rather than in a hospital or skilled nursing facility.

COPAY:

1. BCBS HMO Facility Deductible 40-40%/5800

COINSURANCE:

1. Cigna Health and LIfe Insurance, Cigna Connect 6500
2. Molina Bronze 60 HMO + UnitedHealthcare Bronze HMO A+ Cigna Life Insurance Bronze 60 PPO(40%)
3. Anthem Silver HMO C + Anthem Silver HMO D (70% deductible 30% coinsurance)

NO CHARGE:

1. Molina Minimum Coverage Plan
2. UnitedHealthcare Bronze HMO B
3. Kaiser Permanente Bronze 60 HDHP HMO 7000/0%

 

COMPARISON BY REHABILITATION SERVICES

Rehabilitation services are also primarily for older populations, but can also be required for adults with extenuating circumstances. Their associated costs are outlined below.

 

KEY POINTS

Rehabilitation services: Healthcare service that helps a person regain physical, mental, and/or cognitive abilities that have been lost or impaired as a result of disease, injury, or treatment.

COPAY:

1. Molina Bronze 60 HMO ($65)
2. BCBS HMO Facility Deductible 40-40%/5800 ($40)

COINSURANCE:

1. Cigna Health and LIfe Insurance, Cigna Connect 6500 (50% coinsurance)
2. UnitedHealthcare Bronze HMO A + Cigna LIfe Insurance Bronze 60 PPO (40%)
3. Anthem SIlver HMO C + Anthem Silver HMO D (70% deductible 30% coinsurance)

NO CHARGE:

1. Molina Minimum Coverage Plan
2. UnitedHealthcare Bronze HMO B
3. Kaiser Permanente Bronze 60 HDHP HMO 7000/0%

 

COMPARISON BY HABILITATION SERVICES

Habilitation services are primarily geared towards older people or young people who have been in serious accidents. It is typical to have this type of benefit in a healthcare plan, and the costs are outlined below.

 

KEY POINTS

Habilitation services: Healthcare services that help you keep, learn, or improve skills and functioning for daily living.

COPAY:

1. Molina Bronze 60 HMO + Cigna LIfe Insurance Bronze 60 PPO ($65)
2. BCBS HMO Facility Deductible 40-40%/5800 ($40)

COINSURANCE:

1. Cigna Health and Life Insurance, Cigna Connect 6500 (50%)
2. UnitedHealthcare Bronze HMO A (40%)
3. Anthem SIlver HMO C + Anthem Silver HMO D (70% deductible 30% coinsurance

NO CHARGE:

1. Molina Minimum Coverage Plan
2. UnitedHealthcare Bronze HMO B

N/A:

1. Kaiser Permanentre Bronze 60 HDHP HMO 7000/0%

 

COMPARISON BY SKILLED NURSING CARE

Skilled nursing care is geared towards an aging population, and it would require a skilled nursing facility. The costs are outlined below.

 

KEY POINTS

Skilled nursing care: Intensive care usually required around the clock and rendered by, or under the supervision of, a Registered Nurse or licensed Practical Nurse. Provided only when prescribed by a doctor and usually on an inpatient basis.

COPAY:

1. Cigna Life Insurance Bronze 60 PPO ($65)

COINSURANCE:

1. Cigna Health and Life Insurance, Cigna Connect 6500 (50% coinsurance)
2. Molina Bronze 60 HMO + UnitedHealthcare Bronze HMO A + BCBS HMO Facility Deductible (40%)
3. Anthem Silver HMO C + Anthem Silver HMO D (70% deductible 30% coinsurance)

NO CHARGE:

1. Molina Minimum Coverage Plan
2. UnitedHealthcare Bronze HMO B
3. Kaiser Permanente Bronze 60 HDHP HMO 7000/0%

 

COMPARISON BY DURABLE MEDICAL EQUIPMENT (DME)

Durable medical equipment should be covered under a health plan as they are required in the case of an injury or accident. DME also covers more serious equipment, which is why these costs should have some coverage from a health insurance plan.

 

KEY POINTS

Durable medical equipment: Medical equipment used in the course of treatment or home care, including such items as crutches, knee braces, wheelchairs, hospital beds, prostheses, etc.

COINSURANCE:

1. BCBS HMO Facility Deductible 40-40%/5800 + Cigna Health and Life Insurance, Cigna Connect 6500 (50%)
2. Molina Bronze 60 HMO + UnitedHealthcare Bronze HMO A + Cigna Life Insurance Bronze 60 PPO (40%)
3. Anthem Silver HMO C + Anthem Silver HMO D (70% deductible 30% deductible)

NO CHARGE:

1. Molina Minimum Coverage Plan
2. UnitedHealthcare Bronze HMO B
3. Kaiser Permanente Bronze 60 HDHP HMO

 

COMPARISON BY HOSPICE SERVICES

Hospice services are for aging populations, and for the most part, they do not charge. However, it is important to note which ones require a coinsurance as it may be useful to narrow down choices when choosing a healthcare plan.

 

KEY POINTS

Hospice Services: Care rendered either on an inpatient basis or in the home setting for a terminally ill patient (palliative or supportive care).

COINSURANCE:

1. Cigna Health and Life Insurance, Cigna Connect 6500 (50%)
2. UnitedHealthcare Bronze HMO A + Cigna Life Insurance Bronze 60 PPO (40%)
3. Anthem SIlver HMO D (70% deductible 30% coinsurance)

NO CHARGE:

1. Molina Minimum Coverage Plan
2. Molina Bronze 60 HMO
3. UnitedHealthcare Bronze HMO B
4. Kaiser Permanente Bronze 60 HDHP HMO 7000/0%
5. Anthem SIlver HMO C (100% deductible 0% coinsurance)
6. BCBS HMO Facility Deductible 40-40%/5800

 

COMPARISON BY CHILDREN’S EYE EXAMS

As one of the goals of this task was to find a health insurance plan that took into account vision, these benefits are included. Most plans require a coinsurance as outlined below.

 

KEY POINTS

Children’s eye exams: Price for eye exams for children

COINSURANCE:

1. Anthem Silver HMO D (70% deductible 30% coinsurance)

NO CHARGE:

1. Molina Minimum Coverage Plan
2. Molina Bronze 60 HMO
3. UnitedHealthcare Bronze HMO A
4. UnitedHealthcare Bronze HMO B
5. Kaiser Permanente Bronze 60 HDHP HMO 7000/0%
6. Anthem SIlver HMO C (100% deductible 0% coinsurance)
7. Cigna Life Insurance Bronze 60 PPO
8. Cigna Health and Life Insurance, Cigna Connect 6500

NOT COVERED:

1. BCBS HMO Facility Deductible 40-40%/5800

 

COMPARISON BY CHILDREN’S GLASSES

As vision should incorporate everything from eye exams to glasses, it is important to note this benefit and the associated costs based on the plan.

 

KEY POINTS

Children’s glasses: Price for children’s glasses

COINSURANCE:

1. UnitedHealthcare Bronze HMO A (40% coinsurance)

NO CHARGE:

1. Molina Minimum Coverage Plan
2. Molina Bronze 60 HMO
3. UnitedHealthcare Bronze HMO B
4. Kaiser Permanente Bronze 60 HDHP HMO 7000/0%
5. Cigna Life Insurance Bronze 60 PPO
6. Cigna Health and LIfe Insurance, Cigna Connect 6500

N/A:

1. Anthem Silver HMO C
2. Anthem Silver HMO D

NOT COVERED:

1. BCBS HMO Facility Deductible 40-40%/5800

 

COMPARISON BY CHILDREN’S DENTAL CHECK UP

Dental check-ups are also a typical benefit covered in many insurance plans and for a young population may be important to consider when deciding which plan to buy.

 

KEY POINTS

Children’s dental check up: Price for children’s dental check up

NO CHARGE:

1. Molina Minimum Coverage Plan
2. Molina Bronze 60 HMO
3. UnitedHealthcare Bronze HMO A
4. UnitedHealthcare Bronze HMO B
5. Kaiser Permanente Bronze 60 HDHP HMO 7000/0%
6. Anthem Silver HMO C (100% deductible 0% coinsurance)
7. Cigna Life Insurance Bronze 60 PPO

N/A:

1. BCBS HMO Facility Deductible 40-40%/5800

NOT COVERED:

1. Anthem Silver HMO D
2. Cigna Health and LIfe Insurance, Cigna Connect 6500

 

WHAT WE’RE GOING WITH AND WHY

After extensive research, we have found that a community-based approach to health insurance is feasible, advantageous, and can generate significant savings. Specifically, we have found opting for a Bronze plan for all community members to be the most cost-effective plan for One Community. Our analysis shows that a cost-savings of $1500-$2000 per person per year can be achieved by opting for Bronze plans as opposed to Gold plans. For a population of 500 members, this means that it takes less than 3 days to generate savings sufficient to cover the cost of a medical emergency by covering the Out-of-Pocket Limit. Additionally, we found that with a population of 2000, this community-based approach to health insurance can generate 3 to 4 million dollars of cost savings! We found that at any population size, this approach can generate savings sufficient to cover the entire Out-of-Pocket limit for 30% of the population.

We discuss below the specifics of our findings and our complete thought and analysis process with the following sections:

• Understanding Health Plans Change Every Year
• Projected Costs
  • Premiums
  • Deductibles
  • Trade-Off Between Premium and Deductible
  • Emergency Medical Scenarios
  • Importance of Having Insurance
  • Importance of Prevention
  • Community-Maximized Cost Savings

Based on extensive research of several different insurance plans, the most sustainable plan for our situation would be the UnitedHealthcare (UnitedHealthcare Bronze HMO). To determine this, the plans were analyzed through several different perspectives. First, the top health insurance companies were chosen and then analyzed to find the best options within those insurance carriers. These companies were: Molina Healthcare, UnitedHealth group, Kaiser Permanente, Anthem Healthcare, Cigna Healthcare, and Blue Cross Blue Shield. Each company works to aim for different populations. For example, Molina Healthcare is primarily used to serve underserved and low-income populations while Humana healthcare is primarily for young populations who do not need as much coverage.

Knowing who each company aims to provide for, their plans were analyzed to find which plans offered the most coverage for One Community’s expected residents and their health profile. Once these plans were chosen, they were then analyzed by looking at their summaries of costs, benefits, and coverage. After each plan was analyzed, the most plausible choices were then chosen and compared against each other.

Once these top contenders were selected, they were compared in a spreadsheet in terms of two categories: cost and coverage. To compare the cost of coverage, we used Cost of Premiums, Deductibles, and Out-of-Pocket Limits. To compare the coverage of services we primarily used the coinsurance rates and copays. These features were then assigned scores of 0 to 3 points, and color-coded correspondingly. The plans were ranked by order of highest score for the Costs category, which was our first priority, given most of these final selections should offer sufficient coverage and that we are trying to generate the most cost-savings. The Coverage of Services category was used as an informative category and used for tiebreakers.

Here is the summary of what they offer and how we ranked them. Click the image for the source Google Spreadsheet.

After tallying up the points four plans tied for first for the Costs section: UnitedHealthcare Bronze A, UnitedHealthcare Bronze B, Cigna Health and Life Insurance, Cigna Connect 6500 and UnitedHealthcare Bronze HMO A, and Kaiser Permanente Bronze 60 HDHP HMO. In comparing these plans in terms of services, the UnitedHealthcare Bronze HMO B outscored the other plans in the Coverage of Services category. The UnitedHealthcare Bronze A and Kaiser Permanente Bronze 60 HDHP HMO are also excellent options. It is important to note that the Cigna Plan is an EPO, which means that it is a combination of a HMO and PPO. This type of plan would not be sustainable as there are fewer provider choices. Following that, people under an EPO would require pre-authorizations to get any services they wish to have. This means that people with an EPO must fill several different forms of paperwork with the insurance company before they have access to certain healthcare services. If one fails to get this pre-authorization paperwork completed, he or she will have to cover all of the expenses out-of-pocket.  Under an HMO, one is able to receive a specific service without going through that process. With a more established plan such as one of the UnitedHealthCare HMO plans, it is easier to access providers within the network. EPOs do not provide as broad of coverage of providers for its users, which can make it difficult to have access to quality providers and the ability to choose from each one.

For an organization that is primarily composed of healthy people requiring minimal medical support, it is still important to take into consideration dire-emergency medical expenses that may occur. With an EPO, if there is such a medical emergency, the plan is not efficient in covering those costs, which can lead to very expensive medical bills in the end. An HMO provides more of a safety net when it comes to these types of issues, compared to an EPO, which made the Kaiser Permanente Bronze 60 HDHP HMO and UnitedHealthcare Bronze HMO plans appear to be a better decision than the Cigna EPO plan. Moreover, of these plans UnitedHealthcare and Kaiser Permanente are more reputable companies known for offering good coverage.

As you can see, there were some challenges when it came to the final analysis of the plan to choose. Comparing costs that go by coinsurance and costs that go by copay were a challenge because they do not adhere to the same scale. Furthermore, some plans offered different types of coverage, which made it hard to compare them against other plans.

With all this considered, the UnitedHealthcare Bronze HMO B plan appears to be the best option when it comes to accomplishing the goals for One Community’s insurance plan. It provides the best cost to coverage ratio for a population like the one One Community expects.

 

UNDERSTANDING HEALTH PLANS CHANGE EVERY YEAR

It is important to note that health insurance plans are constantly changing. Though we deemed the UnitedHealthcare Bronze HMO plan to be the best option for One Community, this plan and the other plans analyzed above were no longer available just 6 months after we completed our research. Health insurance companies change their plans every year, so these coverages and benefits may not be the same. Having identified this, we (and anyone else seeking similar benefits) can use the costs and benefits though of UnitedHealthcare Bronze HMO as benchmarks for choosing the appropriate plan when the time comes to purchase one. And though this specific plan no longer exists, similar plans remain an option. It also remains true that for healthy populations, low-premium high-deductible plans (such as Bronze plans) will result in cost savings. We will analyze this strategy further in the subsequent sections.

 

PROJECTED COSTS

PREMIUMS

We compiled a spreadsheet to analyze the costs for the chosen plan, as well as the other options. Monthly premium costs may vary greatly depending on factors such as year, location, and income, so this spreadsheet should be viewed as representing premium estimates. Most of the estimates are based on a 30-year old individual seeking an individual plan in Los Angeles (ZIP 90019) with an income of 35,000 (per capita income in L.A.) in 2022. Previously researched plans are not longer available, so we did our best to find the most similar plan for the purpose of these estimates. Some plans were not offered in L.A. so other locations were used to gather estimates. The monthly premiums for the 9 selected plans range from $232 to $342. The Minimum Coverage plan is the least expensive at $232, the Bronze HMO Plans range from $250 to $275, the Silver HMO plans are $290, and the Cigna plans are $342.

In order to assess the cost of premiums, we used various websites that provide monthly premium quotes. As you can see in the image below, these websites include estimated monthly savings, which seem to primarily be based on an individual’s income. Given that these monthly savings are highly variable and uncertain, we provided the full premium quote. For instance, in the example in the image below, the full premium is $248.79 (the listed premium of $162.19 + the monthly savings of $86.60). Therefore, be aware that the monthly premiums provided in our spreadsheet are prior to any discounts or savings.

 

DEDUCTIBLES

In addition to comparing the premiums for the plans we analyzed, we compared the deductibles. The deductible is the price that must be paid before the insurance plan kicks in. See the Deductible Comparison Tab on the spreadsheet to view these comparisons. This spreadsheet shows the deductible for an individual, and shows the cost of paying deductibles for communities of 50, 100, 500, and 2000 people.

 

TRADE-OFF BETWEEN PREMIUM AND DEDUCTIBLE

There is an inverse relationship between the cost of premiums and deductibles. This means that lower premium plans have higher deductibles and higher premium plans have lower deductibles. Finding the optimal balance between these variables is dependent on an individual’s characteristics, including their health and how often they expect to require medical services.

For a population like One Community that has a non-toxic living environment, exceptional nutrition and food quality, regular exercise, and generally good health to begin with, this population can be expected to not have frequent or dire medical needs. For such a population, opting for low-premium, high-deductible plans will result in cost-savings. Additionally, such a community can cover the deductible costs to mitigate the downside of high deductibles. A community-based approach to health insurance can generate cost-savings sufficient to cover not only these high deductibles but also the entire out-of-pocket limits, such that the individuals don’t have to worry about these costs. See the Community-Maximized Cost Savings section for more details about how these cost-savings are generated.

 

EMERGENCY MEDICAL SCENARIOS

In the case that there are medical emergencies, having a health insurance plan is critical. Without insurance coverage, individuals may quickly fall into crippling debt. In an effort to demonstrate this, we researched the costs of the most expensive types of medical procedures. Here are a handful of some of the most expensive procedures:

1. Heart Transplant -$1,382,400

• • About 3,500 heart transplants are performed each year in the U.S, which is about 0.001% of the U.S. population

2. Lung Transplants (single or double) -$135,622

• • About 1,400 lung transplants are performed each year in the U.S. (some of which are single lung transplants, but most of which are double) this accounts for about 0.0004% of the U.S. population

3. Intestine Transplant-$1,147,300

• • About 2164 transplants between 1990 and 2011, which comes out to about 100 per year, which is about 0.00003% of the U.S. population

4. Allogeneic Bone Marrow Transplant-$193,000

• • In 2017 there were 45,418 bone transplants, 27,137 of which were allogeneic, which accounts for 0.008% of the U.S. population

Though not one of the most expensive medical expenses, heart attacks can be very costly and are much more common than the emergencies listed above. Every year about 805,000 people in the U.S. have a heart attack (0.2% of the population). Shown below is a breakdown of what the projected costs would look like for a heart attack (Click here for link to spreadsheet). However, it is important to note that this is just an estimate. A primary care doctor would be key in directing which type of care a person would receive and that will affect how much everything would ultimately cost. As you can see in the table below, without any insurance a heart attack might cost $944,655. However, with a Bronze HMO Plan the individual will only be financially responsible for a maximum cost equalling their plan’s out-of-pocket limit, in this case $8,150. Therefore, in this case, health insurance will cover 99.1% of the medical costs. The third column of the table below demonstrates the cost savings if only the coinsurance policies were followed, but there was no out-of-pocket limit. In this case, the individual would be responsible for about $377,150, still a savings of $567,5050 (about 60% of the total cost), but still a hefty sum for an individual to cover. This highlights the importance of the out-of-pocket limit.

Our calculations show that, using a collaborative approach to community insurance, the entire out-of-pocket limit for community members should be able to be covered by the cost savings of opting for a low premium plan. Our analysis has found that with a population size of 500, it would take only 2-3 days of savings in premium costs (by opting for bronze plans instead of gold plans) to cover the out-of-pocket limit for one individual. See the Community-Maximized Cost Savings section for more details about this analysis and plan.

 

IMPORTANCE OF HAVING INSURANCE

No matter your age, general health, or preventative measure, medical emergencies can happen to any of us. This example above makes it very evident how important it is for individuals to be covered under a health insurance plan. In situations like these, it is important to have a health insurance plan that provides effective coverage so that the high expenses don’t become financially crippling. The examples above demonstrate just how crippling it could be, and how effectively health insurance coverage minimizes the financial burden.

Collaboratively covering insurance is a great solution to maximize the benefits of lower-premium insurance by generating savings sufficient to cover deductibles and out-of-pocket limits if needed. Our analysis suggests that even at a community size as small as 50, it will take only a month of savings in premium costs (by opting for bronze plans instead of gold plans) to cover the out-of-pocket limit for one individual. Though it would take longer to generate these savings, it stands to reason that this principle will also hold for smaller groups of individuals interested in collaborating to cover health insurance costs.

 

IMPORTANCE OF PREVENTION

Though we cannot entirely eliminate the risk of medical emergencies, we can employ many preventive measures to decrease their likelihood. Most of the most expensive procedures are related to issues such as heart conditions and cancer. Nearly half (50%) of American Adults suffer from cardiovascular disease. Here are some of the most effective preventative lifestyle factors:

• Eat healthy – Try to limit saturated fats, sodium, and added sugars and eat plenty of fresh fruits, veggies, and whole grains
• Get regular exercise – The benefits of exercise are significant in many aspects of health
• Manage stress – Use healthy coping strategies such as exercise, music, or meditating
• Control blood pressure – Check your blood pressure regularly, and seek medical advice if needed
• Control your cholesterol and triglyceride levels – both of these are risk factors for heart disease, manage them with lifestyle factors and medicine if need be
• Maintain a healthy weight – Weight is associated with risk factors such as high cholesterol, high blood pressure, and diabetes
• Limit alcohol and don’t smoke – These two drugs can increase blood pressure which increases the risk of heart disease
• Get enough sleep – Most adults need 7 to 9 hours of sleep a night

High blood pressure, high blood cholesterol, and smoking are some of the biggest factors leading to cardiovascular disease. However, these factors can be prevented by the measures mentioned above.

Cancer is also responsible for many of the highest medical expenses. Cancer affects around 39.5% of men and women. Often cancer can cause patients to get several surgeries, including the ones listed above. The likelihood of developing cancer can also be reduced by eating healthy, living an active lifestyle, and living in healthy, safe, and clean environments. While both cancer and cardiovascular disease have genetic factors, the likelihood of developing these diseases can still be significantly reduced by applying the preventive aforementioned measures.

One Community will have many preventative measures at the core of its culture, including a nontoxic living environment, healthy food, and regular exercise.

 

COMMUNITY-MAXIMIZED COST SAVINGS

Bronze HMOs have the lowest premiums, but higher copays and coinsurance costs. However, for people who do not require as many medical services, in the long run these high prices are still less expensive overall because healthy people don’t utilize these services often. For this reason, these types of plans are geared to people who do not have dire medical needs, but still need routine care.

With a community-based approach to health insurance, the savings generated by opting for low premium plans can be maximized and pooled to cover medical expenses for community members when medical emergencies arise. This plan works best when the majority of the population is healthy and will infrequently require high medical costs. If a higher proportion of persons in a community require more extensive care, then this approach of opting for bronze plans may not be as suitable to their needs as the high copays and coinsurance will end up being a burden. Ultimately, this plan will be most cost-effective for communities in which the majority of members do not require extensive care, but still need routine coverage with no serious expenses.

Below is an image of the tab in the spreadsheet in which we calculate estimated premium costs and cost-savings by opting for a bronze plan. In the green section of the table you can see average monthly premiums for gold vs. bronze insurance plans, and how much this would sum to for different population sizes. The blue section shows the difference in premium costs between bronze and gold plans, demonstrating the cost-savings of selecting a bronze plan, and how these savings scale depending on population size. Additionally, the blue section last row also shows how many community members’ full Out-of-Pocket limits can be met by these savings. In the purple section, you can see estimates for how long it would take to generate savings sufficient to cover a medical emergency of a One Community member by meeting the Out-Of-Pocket Limit.

To highlight a few of our findings displayed in the table above, we found an average savings of about $1500 to $2000 per person per year by opting for a bronze plan as compared to a gold plan. As the population scales, these savings multiply, reaching about 3 to 4 million dollars (annually) with a population size of 2,000. To give us a sense of the importance of these savings, we calculated how long it would take for these generated savings to cover the cost of medical emergencies within the community. Impressively, at a population of 50 people it takes only about a month to save enough to cover the entire out-of-pocket limit for an individual. And once you reach a population of 2000, this number is less than 1, meaning each day you save more than enough to cover a person’s out-of-pocket limit. These findings significantly validate the plan to opt for a bronze plan.

This community-based health insurance approach is possible for ANY group of people who trust each other and are generally healthy. One of our most significant findings was that at any population size, this plan can generate savings sufficient to cover the entire Out-of-Pocket limit for 30% of the population. This proportion can be used as a benchmark to assess whether this community-based health insurance approach is right for a given community. On average, if more than 70% of the population is generally healthy and not likely to require frequent medical service* then this community-based insurance approach is likely to be cost-effective.

However, it is important to remember this is the best plan for a population that will not require frequent medical services*. Consequently, for high-risk people/populations who desire more coverage, other options might be optimal/preferred. In such cases, it might be most cost-effective to have a plan that has lower up-front costs (copays and coinsurance) for medical services. This comes at the cost of having higher monthly premiums, but if one were to be receiving lots of medical care, it would save that person more money to pay lower in copays and coinsurance, as that is where most of the expenses would be coming from.

* For clarity, “frequent medical service” includes: Individuals with chronic conditions requiring regular medical care, the most common of which are heart disease, cancer, stroke, respiratory disease, arthritis, diabetes, Alzheimer’s and dementia, and kidney disease. Most (possibly all) of these are related to avoidable risk factors such as poor diet, lack of exercise, high stress, high blood pressure, obesity, and smoking.

 

SUMMARY

The goal of this page was to identify the most affordable and appropriate health insurance options for a community of 50+ individuals living and working together in the United States. When choosing a health insurance plan, one of the first things to decide is whether to go with a group plan or individual plans. Next you need to choose what type of plan, such as Medicare, fixed indemnity plans, critical illness insurance, HMOs, PPOs, POSs, HDHPs, etc. Another important factor is whether to opt for low-premium, high-deductible plans or high-premium, low-deductible plans. In this case, given that One Community’s population will be generally healthy and will be living in a nontoxic environment with healthy food and active lifestyles, we expect relatively infrequent medical services.

Our analysis of 43 insurance plans across 10 insurance providers found that the best option was UnitedHealthcare Bronze Plan B, closely followed by UnitedHealthcare Bronze Plan A and Kaiser Permanente Bronze 60 HDHP. The average monthly premium for a bronze-level plan in California is $314, but our top-evaluated plans range from $249-255, which amounts to a savings of over $700 per year per person. Though these specific plans as they were researched for this analysis are no longer offered, the specifications of these plans are useful benchmarks for choosing a similar plan. More generally, we found that significant cost-savings can be achieved by opting for a Bronze Plan (low-premium, high-deductible). Comparing Bronze plans to Gold plans, we found that with a population size of 500 people, in a matter of 2-3 days the lower premiums of bronze plans result in cost savings sufficient to cover the costs of any health emergency by covering the entire out-pocket-limit for one individual. These savings scale impressively, as we found that with a population of 2000, this plan would generate  3 to 4 million dollars of cost savings! And to reiterate one of one most significant findings: this plan can generate savings sufficient to cover the entire Out-of-Pocket limit for 30% of the population. This means that for ANY group of people who trust each other, if more than 70% of the population is generally healthy, a community-based approach to covering health insurance is likely to be cost-effective.

 

RESOURCES

• Article: Health Insurance Glossary
• Website: General Information on Health Insurance Plans
• PDF: Summary of Benefits and Coverage (SBC), Molina Silver 94 HMO
• PDF: SBC, Molina Silver 87
• PDF: SBC, Molina Silver 70
• PDF: SBC, Molina Bronze 60
• PDF: SBC, Molina Gold 80
• PDF: SBC, Molina Platinum 90
• PDF: SBC, Molina Minimum Coverage HMO
• Website: Dataset of UnitedHealth Care SBC
• Website: Dataset of Kaiser Permanente SBC
• Website: Dataset of Anthem SBC
• PDF: Humana Value Plus HMO
• Website: Dataset of BCBS SBC
• Article: Steps to Self-Insurance
• Article: Comparison of Individual Health Insurance vs. Group Health Insurance
• Article: Group Health Insurance
• Article: Two Health Insurance Plans
• Article: Catastrophic Health Plans
• Article: Coinsurance vs. Copays
• Article: HMO vs. PPO
• Article: High Deductible Health Plans
• Article: What is a PPO
• Article: Common Questions About Health Insurance
• Article: 10 Questions to ask about Healthcare
• Article: Questions to ask about Healthcare
• Article: Buying Health Insurance
• Article: Essential Health Benefits
• Article: Drivers of Health Insurance
• Article: High Deductible Employer Plans
• Article: Medicaid
• Article: Average Marketplace Premiums by Metal Tier

 

GLOSSARY

Childbirth/delivery professional services: Services provided by a professional for a patient undergoing childbirth.

Childbirth/delivery facility services: The price for the facility used during the childbirth/delivery procedure.

Children’s eye exams: Price for eye exams for children

Children’s glasses: Price for children’s glasses

Children’s dental check up: Price for children’s dental check up

Copay: A fixed out-of-pocket amount paid by the insured for covered services

Coinsurance: A type of insurance in which the insured pays a part of the claim. Ex.80% coinsurance=insurance company is responsible for 80% and you are responsible for 20% plus deductible.

Deductible: The amount you pay for covered health care services before your insurance plan starts to pay.

Diagnostic Test: An examination to identify an individual’s specific areas of weakness and strength. It used to determine a condition, disease, or illness.

Durable medical equipment: Medical equipment used in the course of treatment or home care, including such items as crutches, knee braces, wheelchairs, hospital beds, prostheses, etc.

Emergency Medical Transportation: Cost to transport patients to the emergency room.

Emergency Room: All services provided when a patient visits an emergency room for an emergency condition.

Facility Fee: Charge you have to pay when you see a doctor that is not owned by that doctor.

Habilitation services: Healthcare services that help you keep, learn, or improve skills and functioning for daily living.

Home health care: Part-time care that is provided by medical professionals in the home setting rather than in a hospital or skilled nursing facility.

Hospice Services: Care rendered either on an inpatient basis or in the home setting for a terminally ill patient (palliative or supportive care).

Imaging: Techniques and processes used to create images of various parts of the human body for diagnostic and treatment purposes (X-ray, MRI, etc.)

Inpatient Services: The services of a patient who has been admitted to a hospital for at least 24 hours.

Non-Preferred generic/brand drugs: Equivalent to to Tier 4

Office visit Primary care: The amount you pay when you go to the office to receive routine care from your primary care provider for pregnancy.

Office visit Specialist care: The amount you pay when you go to office to receive care from some type of pregnancy specialist.

Out-of-Pocket Limit: The most you have to pay for covered services in a plan year. After you spend this amount on deductibles, copayments, and coinsurance for in-network care and services your health plays 100% of the costs of covered benefits.

Outpatient Services: A term referring to the services of a patient who receives care at a medical facility but who is not admitted to the facility overnight, or for 24 hours or less.

Outpatient Surgery: Surgery and discharge done the same day and no overnight stay is required.

Physician/Surgeon: Cost of having a physician/surgeon+their services

Preferred Brand Drugs: Equivalent to Tier 3

Preferred Generic Drugs: Equivalent to Tier 1

Preventive Care: Care you receive to prevent illnesses or diseases.

Primary Care Visit: Healthcare for day-to-day issues. Usually the first point of contact and principal point of continuing care for patients within a healthcare system.

Rehabilitation services: Healthcare service that helps a person regain physical, mental, and/or cognitive abilities that have been lost or impaired as a result of disease, injury, or treatment.

Skilled nursing care: Intensive care usually required around the clock and rendered by, or under the supervision of, a Registered Nurse or licensed Practical Nurse. Provided only when prescribed by a doctor and usually on an inpatient basis.

Speciality Drugs: Tier 5 Drugs. Most expensive drugs. Used to treat complex conditions, can be generic or brand name.

Specialist Visit: Health care provided by specialty doctors for a specific area of medicine-usually referred to a specialist from a primary care provider.

Tier 1-Preferred generic drugs: Commonly prescribed generic drugs.

Tier 2-Generic drugs: Cost a little bit more than Tier 1 drugs.

Tier 3-Preferred brand drugs: Brand name drugs that do not have a generic equivalent drug. The lowest cost brand name drugs.

Tier 4-Non preferred drug: Higher priced brand name and generic drugs that are not in a preferred tier.

Urgent care: Diagnosis and treatment of medical conditions, which are serious or acute but post no immediate threat to life and health but require medical attention within 24 hours. Different from an emergency room as it relates to less serious health problems.

 

FREQUENTLY ANSWERED QUESTIONS

Q: What is Medicaid?

Medicaid is a health insurance plan funded by states and the federal government. It is a health insurance plan that provides coverage for many Americans who are of low-income.

Q: When is open enrollment?

Open enrollment usually starts on November 1, 2020. It usually ends on December 15, 2020.

Q: What is open enrollment?

The yearly period when people can enroll in a health insurance plan.

Q: How does one go about choosing a plan?

Essentially, one should take into account his or her needs and then align them with the plans they are looking at. It would be a good idea to talk to an insurance agent when deciding which plan to buy.

Q: Where do people usually buy plans?

This is entirely up to the consumer, but generally people who are employed get the plans offered by their employer. You can also buy your own insurance through a broker. The health insurance marketplace also sells plans with the help of the Federal government. There are also government aided healthcare plans such as Medicare and Medicaid.

Q: How should one budget their health insurance/medical expense costs?

Although a tedious task, one should always keep track of their costs and receipts. Following that, maintaining a dialogue with one’s providers about costs as well as how often he or she should meet with them is a useful way to keep track of visits and payments. It is also a good idea to save for unexpected costs.

Q: Where can I get information about my health plan?

Anyone who has an insurance plan is entitled to see a summary of benefits and coverage. It is usually provided by the company or employer.

Q: Can I change my health plan?

You can change your health plan once a year, during the renewal period. However, under extenuating circumstances, you may also be able to change your health plan outside of the renewal period.

Q: Will this health insurance plan help me save money?

If one is healthy and does not require serious medical attention, having an expensive healthcare plan may be a burden. Therefore, it would be useful to analyze costs such as the monthly premium, copays, and how this plays into one’s budget.

Q: What are key aspects to look for in a healthcare plan?

Ultimately, one can get a good picture of their healthcare plan by analyzing the monthly premium, deductible, out-of-pocket maximum, and copays for services that are important to them.

Q: What are important benefits to have in my health insurance plan?

Typically, most plans will cover doctor’s services, pregnancy and childbirth, mental health services, pharmacy, and emergency/hospital (inpatient and outpatient) room services. There can be many other benefits as well, and it requires a bit more thorough research.

Q: What is ObamaCare?

Obamacare, which is also known as the Affordable Care Act is a law that ensures that all Americans should have access to affordable health insurance. Essentially, Obamacare is a set of laws that sets requirements for one’s access to health insurance.