|
|
May 2006
The UUA Health Plan Office has prepared this guide to help individuals and congregations make informed decisions about joining the UUA Health Insurance Plan. Health insurance is one of the most important—and costly—purchases you make. Read this information along with the detailed plan descriptions on our website, and complete the worksheet at the end. We are available in the Health Plan Office at healthinsurance@uua.org 
to help with any questions.
HMOs, PPOs, and Indemnity Plans
Most residents on the Atlantic and Pacific Coasts and in most large metropolitan areas are familiar with Health Maintenance Organizations. HMOs offer a restricted panel of physicians and hospitals, and put the focus on preventive medicine, easy access to routine care, and on closely managing healthcare expenditures. HMOs are less common in other parts of the US . Most HMOs require patients to have their care directed by a gatekeeper, a primary care physician who controls the patient's access to specialists, expensive diagnostic procedures, and other high-priced services. HMOs offer no reimbursement for treatment outside their network—something that many people find burdensome. Depending on their efficiency and panel of doctors, the premiums charged by HMOs are generally lower than what PPOs charge, and nearly always well below the rate charged by open-ended Indemnity Plans.
Indemnity Plans are at the other end of the spectrum from HMOs. They cover visits to any doctor, any specialist, and any other medically necessary service, usually with few managed care controls. There are still some indemnity plans around, but in nearly all markets, they have been priced out of business.
Preferred Provider Organizations, or PPOs, represent the middle ground between HMOs and indemnity plans and are very popular with both employers and employees. PPOs work to preserve the best features of HMOs, such as affordable routine care, preventive services, and checkups, while eliminating gatekeepers and opening up access to all of the providers in the community. PPOs rely on members using "in-network" doctors and hospitals for most of their care. In-network providers have agreed to reduce their charges in exchange for higher patient volume. The in-network providers are the "preferred" ones, and the PPO pays a higher percentage of their claims, generally 90 or 100 percent. When members want to see an "out-of-network" provider, they are free to do so, and they will pay a larger share of the bill.
The UUA has chosen to offer two PPOs: a standard plan that offers benefits that closely mirror HMO plans for in-network care; and one with a high deductible, for those who want a lower premium and are willing and able to budget for unforeseen expenses.
Once you understand the general shape of your plan—HMO, PPO, or Indemnity Plan—the monthly premium is the next thing to consider. Because it is such a convenient yardstick, the premium is also the most likely source of surprise, both pleasant and not, and individual experience with the UUA plan will vary widely. Here's why:
- Some people are in group plans, either through their partner's plan, or through their congregation if it is part of some larger business group or can buy its own policy, or perhaps they are on a COBRA continuation. Group plans are priced entirely differently than a new plan like ours, where all of the details of the people who will enroll are unknown. When people in a group plan look at the UUA plan rates, some will find our rates to be much higher, some much lower, some about the same. In any case, you will be looking at the real cost of healthcare for someone of your age living in your zip code.
- Other people are already in "non-group" plans, the plans that are most often available to individuals who cannot get coverage through their employer. These individual plans generally use age and geography to match the premium to the individual. People in non-group plans will generally find the UUA plan to be quite competitive, with most rate differences based on the benefit design.
Remember that when you compare rates, it's important to compare premiums for the same year. The rates publicized for the UUA health plan will be in effect for all of 2007. Other plans with premiums current for 2006 will likely raise their 2007 premiums by 9% to 12%, based on recent history and current industry projections.
You can check your 2007 cost.
For many people, being able to keep their doctor (or their partner's doctor, or their pediatrician) is the single most important factor in choosing a new plan.
The Blue Cross Blue Shield network used by the UUA plan has over 720,000 providers who have agreed to be "Preferred Providers"—it is twice the size of the next largest network. The larger the provider network, the greater chance of finding your particular doctor on the list of in-network providers, and thus available to you at a lower cost. Some plans have providers only in major metropolitan areas, making the costs of care much more expensive for members in less populated parts of the country.
Blue Cross maintains a regularly updated list of providers that you can access online at www.highmarkbcbs.com
by following the "Find A Provider" link on the right. Highmark also maintains a help line, (800) 810-2583 where a customer service representative can do the lookups for you.
Benefits drive the cost of a health plan, and all plans try to balance benefits and cost. All plans limit payment for non-essential or experimental treatments, job-related expenses, most cosmetic treatment and a range of other "exclusions".
The UUA plan offers a broad range of benefits including 100% (after the co-pay) of the cost of preventive care for adults and children, plus hospice, midwife services, mental health treatment, and private duty nursing, and prescription drugs, to name only a few examples. Unlike many other plans, it includes pregnancy terminations, and transgender surgery up to a fixed amount. Benefit details.
To understand benefit details, you will have to do some homework. We've included a worksheet to make the analysis easier. Fill in as many of the categories as interest you, and then make your decision. Some people will not go further than the monthly premium and "Is my doctor in the plan?" Others will go a little deeper. If you need help interpreting some part of your coverage choices, you can email healthinsurance@uua.org
Here are a few terms you will need to know:
- Co-pay. Think of the co-pay as the admission fee for access to a provider. This is the amount the patient pays "up front" at the doctor's office, hospital ER, or when filling a prescription. The co-pay is kept by the provider as part of their payment for providing the service. The co-pay does not count toward the deductible.
- Deductible. A deductible is the amount that a patient is responsible for before the insurance plan accepts responsibility for its share of payments to providers. Deductibles commonly range from $250 to $1,000 or more.
- Coinsurance. After the deductible has been met, this is the percentage that the plan pays of the balance. Many plans apply a deductible and coinsurance, usually 70%, 80%, or 90%, to all services. Some plans, like the standard PPO that the UUA offers, cover some services at 100%, often without a deductible. This is an area where you have to read your coverage documents.
- Out-of-pocket Maximums. Most plans, but not all, limit your financial exposure in a calendar year. The UUA standard PPO, for example, limits your exposure to $2,000 per individual, and no more than $4,000 per family. These limits to a subscriber's financial exposure are often overlooked. Some commercial plans can offer low premiums because the patients assume a very large risk for catastrophic care. (In the insurance world, the word "catastrophic" refers not to the disease but to the high cost of treatment.)
Before you begin, keep in mind some key questions:
- What gets paid at 100%? How much is the co-pay?
- What else is covered, but at less than 100%? How much is the deductible? What is the coinsurance percent?
- Is there any protection against large out of pocket costs for me in a calendar year? (The UUA plan has both individual and family limits.)
- Does the plan cover prescription drugs? What are the co-pays? Are generics and brand names covered differently?
- What are the exclusions? The big ones to watch for are exclusions for preventive care, pregnancy termination, dental injures, prescription drugs, and treatment for mental illness.
- Does the plan cover pre-existing conditions? Group plans will make some kind of provision for coverage at some point in time. Non-group, or individual, plans can be very restrictive.
When an insured person relocates to a new area, he or she often loses their previous coverage and must find a new insurance carrier. This can impose hardships on persons who have been receiving treatment for chronic conditions such as diabetes or some pulmonary problems. They may find it impossible to obtain insurance that will cover their pre-existing condition.
Since the health plan offered by the UUA uses a nationwide network of providers and is controlled by the UUA, the plan is completely portable within the US . Ministers and other staff who take positions in new locales will not lose their insurance, although they will want to find a new primary care physician. Even your ID card goes with you when you move—it's recognized nationwide.
The UUA plan also covers urgent and critical care anywhere in the world.
In addition to the decisions that individuals have to make about the UUA health plan, congregational leaders must make some decisions.
The first responsibility of congregational leaders is to make sure that all eligible staff know about the plan. We have made every effort to reach people directly, but there are some staff for whom we may not have addresses.
Your second responsibility is to discuss with your Board how your congregation will approach funding health insurance. We encourage all congregations to contribute at least 80% of the cost for this Plan for employees, and at least 50% of the cost for additional family members, and we understand that for some that will be a goal, not a first year reality. We encourage you to be creative—think about how the January startup might impact only half your fiscal year; think about prorating your contributions based on hours worked. Your District Compensation Consultants and the UUA Health Plan Office are available to help you work through this planning.
Beyond letting people know what their options are and evaluating your funding options, your next steps depend on whether or not your church has a contract for a group insurance plan. If not, if your congregation simply allows staff to choose if and how they buy health insurance, nothing more is required. If your church does purchase some form of group coverage, here are some other things to consider:
- Cancelling current coverage. Group plans have contractual provisions for cancelling coverage. Typically, 30 days' notice is required, or you will be responsible for another month's premium. Make sure you read the policy provisions to be sure. Do not cancel your current policy until the UUA has notified congregations that we have reached our enrollment target and the Trustees have voted in October to have the plan go forward. Remember that the effective date for the UUA plan will be January 1, 2007, which may or may not match the anniversary date of your group insurance policy.
- Offering more than one plan to your employees. It may be possible to continue offering your current plan, with the UUA plan as an additional option, but it is likely to be difficult under the participation rules used by most insurance companies and HMOs (but not our plan). Most require that at least 80% of the employees eligible to participate actually join their plan, and there are some that will not agree to be offered alongside any other plan. To be sure, it's best to read your contract, and if you still have a question, contact your insurance company and ask them.
Now that you have the basic facts about comparing health insurance plans, you can go on to the worksheet 
. We've filled in the blanks for the two UUA plans. Read the documents for your current plan, if you have one, and fill in the worksheet in as much detail as you need to make a decision. We are available in the Health Plan Office at healthinsurance@uua.org to help with any questions.
accesses to this page since May 2, 2006