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Waiting for 2014

As we have so often observed over the past months, no one knows just what’s going to happen with healthcare reform legislation.  There are threats and promises on all sides; demands for repeal are countered with equally demanding cries for more reform.  In the meantime, should you or a loved one need to find some health insurance, the process remains confusing, exasperating and expensive.

Consumer Reports recently reviewed more than 800 private, Medicare and Medicaid health insurance plans that had been ranked according to the standards of the nonprofit National Committee for Quality Assurance (NCQA), a highly respected independent quality-measurement group.   Their rankings are interesting, some of their findings unexpectedly so.  For one thing, bigger is emphatically not necessarily better.

And for another thing, according to CR, a national brand does not ensure quality.  The nation’s five largest insurers – Humana, Cigna, Aetna, UnitedHealthcare and Kaiser Permanente – taken together with the 60 essentially state-based Blue Cross Blue Shield plans account for 75 percent of the 390 ranked private plans but for only 36 percent of the top 50.  Private plans are those plans we obtain on our own or join through an employer.

For example, UnitedHealthcare is this country’s largest health insurer, with some 33 million enrollees.  And not one of their plans ranks among the top 100 plans.  Indeed, most of their offerings are at the bottom half of the rankings.  And very few of its Medicare HMOs and PPOs are in the top 100 of the 341 ranked Medicare plans.

Cigna, with more than 11 millions members,  has several HMOs in the top 100 of the 390 ranked private plans, but its PPOs are at the absolute bottom, ranking below 300.  The PPOs are in the accrediting process, but still.

Many of the smaller, community-based and mostly non-profit  plans did better, and almost all of Kaiser Permanente’s private and Medicare HMOs were found to be better than average (for treatment and prevention both) and were among the highest ranked.  The company has an enrollment of about 8.8 million.

This is the second year that Consumer Reports has published NCQA insurance plan rankings.  All 50 states and Washington D.C. were included.  An estimated 127 million Americans are covered by the plans that the NCQA ranked, through private coverage, Medicare and/or Medicaid.  This is the first year that the NCQA took on ranking PPOs, which enroll about 34 percent of the US population and 60 percent of those receiving coverage through large employers.  HMOs enroll 31 percent of the population.

A quick guide to HMOs, PPOs and high deductible plans

You already understand that the kind of health insurance you buy, or are enrolled in as a family member,  has significant impact on your out-of-pocket expenses, your ability to choose networks and physicians, perhaps even the quality of your care.

The HMO – health maintenance organization:

  • You must get care from providers in the plan’s network
  • The network is often limited to a certain geographical region
  • Your primary care physician oversees and coordinated your health care and controls referrals to specialists
  • Out of network, you pay the full cost of care, except for emergencies.
The PPO – preferred provider organization:
  • You can see any in-network provider without a referral.
  • If you go outside the network, you can still get care, but you will pay a higher portion of the bill.
The POS – point of service:
  • The HMO/PPO hybrid.  You choose a primary care doctor.  You will need a referral for a specialist.  But you are covered for out-of-network providers.
The High Deductible plans
  • These are the plans that, in order to reduce premiums, have very high deductibles.  Often paired with health savings accounts or health reimbursement accounts. These accounts allow you to use tax favored funds to pay for qualified medical expenses, including the deductibles, co-pays and so on.
How to decide which one?
  • Less paperwork? Since your share of the medical costs is mainly seen as up-front co-pays, you are unlikely to have to deal with claims or pay any balance due.
  • More choices? PPOs and POSs offer more access to specialists and out-of-network care.  
  • Coordination of care?  Your primary care doctor in an HMO manages your care, which includes scheduling preventive services and screenings.
  • Lower premiums? High deductible plans – but be careful.  Unless you use the HSA portion properly, you could face enormous costs should you become seriously ill.
  • Wellness programs and disease management? Most modern policies from all types of plans offer these programs.  As the programs themselves and the eligibility requirements vary, get details before you decide.



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One response to “Waiting for 2014

  1. Pingback: Options To Compare Insurance Companies | TIB Tips

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