Marvel Alder Lucy Aspera Erica Millan Tiffany Suh

Marvel AlderMarvel AlderLucy AsperaLucy AsperaErica MillanErica MillanTiffany SuhTiffany Suh

Introduction Introduction Managed Care health insurance offers low cost Managed Care health insurance offers low cost moderate health care coverage. It’s a system moderate health care coverage. It’s a system that controls the financing and delivery of that controls the financing and delivery of health services to members who are enrolled in health services to members who are enrolled in a specific type of healthcare plan.a specific type of healthcare plan.

The goals of managed health care are to ensure that...The goals of managed health care are to ensure that... providers deliver high-quality care in an environment providers deliver high-quality care in an environment

that manages or controls costs. that manages or controls costs. the care delivered is medically necessary and the care delivered is medically necessary and

appropriate for the patient’s condition. appropriate for the patient’s condition. care is rendered by the most appropriate provider. care is rendered by the most appropriate provider. care is rendered in the most appropriate, least-care is rendered in the most appropriate, least-

restrictive setting.restrictive setting.

Introduction Cont. Introduction Cont.

The basic concept The basic concept behind managed behind managed health care is to health care is to lower cost by means lower cost by means of control, by of control, by controlling access to controlling access to providers the costs providers the costs are controlled as are controlled as wellwell

Costs InvolvedCosts Involved

Monthly health Monthly health insurance insurance premiumpremium

Co-paymentCo-payment Cost depends on Cost depends on

whether you’re whether you’re in-network or in-network or out-of-network. out-of-network.

Different types of health Different types of health coverage:coverage:

1.1. Health Maintenance Organization (HMOs) Health Maintenance Organization (HMOs)

2.2. Preferred Provider Plans (PPOs)Preferred Provider Plans (PPOs)

3.3. Medical Savings Plan (MSP)Medical Savings Plan (MSP)

4.4. Point of Service Plans (POSs) Point of Service Plans (POSs)

HMO’sHMO’s

A Health Maintenance Organization A Health Maintenance Organization (HMO) is an organized system of health (HMO) is an organized system of health care that provides comprehensive services care that provides comprehensive services to its members for a fixed, pre paid fee.to its members for a fixed, pre paid fee.

HMOs are the least expensive form of HMOs are the least expensive form of managed medical care. managed medical care.

About HMO’sAbout HMO’s

HMO's account for a significant share of HMO's account for a significant share of the group health insurance in the market, the group health insurance in the market, in 2001, enrollment in HMO's accounted in 2001, enrollment in HMO's accounted for 33 percent of all employee enrollments for 33 percent of all employee enrollments in health insurance plans.in health insurance plans.

How HMO’s WorkHow HMO’s Work

The member picks a provider The member picks a provider A list is set up of the physicians that are A list is set up of the physicians that are

covered under the HMO plan and from covered under the HMO plan and from there the member picks their primary care there the member picks their primary care physician. physician.

The primary care physician must refer a The primary care physician must refer a patient out in order to see a specialist. patient out in order to see a specialist.

Types of HMO’sTypes of HMO’s

There are four types of HMO’sThere are four types of HMO’s

Staff ModelStaff Model- physicians are employees of the HMO and are paid a - physicians are employees of the HMO and are paid a salary and possibly and incentive bonus to hold down costs. salary and possibly and incentive bonus to hold down costs.

Group ModelGroup Model -physicians are employees of another group that have -physicians are employees of another group that have a contract with an HMO to provide medical services to its members. a contract with an HMO to provide medical services to its members. The HMO pays the group of physicians a monthly or annual The HMO pays the group of physicians a monthly or annual capitation fee for each member. In return, the group agrees to capitation fee for each member. In return, the group agrees to provide all covered services to the members during the year. The provide all covered services to the members during the year. The group model typically has a closed panel of physicians that requires group model typically has a closed panel of physicians that requires members to select physicians affiliated with the HMOmembers to select physicians affiliated with the HMO

Cont. Types of HMO’s Cont. Types of HMO’s

Network Model -the network contracts with two or more independent group practices to provide medical services to covered members. The HMO pays a fixed monthly fee for each member to the medical group. The medical group then decides how the fees will be distributed among the individual physicians.

Individual Practice Association (IPA) -is an open panel of physicians who work out of their own offices and treat patients on a fee for service basis. However, the individual physicians agree to treat HMO members at a reduced fee.

Advantages of HMO’sAdvantages of HMO’s

Most services are covered in full with relatively few maximum limits Most services are covered in full with relatively few maximum limits on individual services.on individual services.

Covered services typically include the full cost of hospital care, Covered services typically include the full cost of hospital care, laboratory and X-ray services, outpatient services, special-duty laboratory and X-ray services, outpatient services, special-duty nursing, and numerous other servicesnursing, and numerous other services

Office visits to HMO physicians are also covered, either in full or at Office visits to HMO physicians are also covered, either in full or at a nominal charge for each visit.a nominal charge for each visit.

Some newer HMOs allow insured's to select any physician at Some newer HMOs allow insured's to select any physician at higher out-of-pocket costs. higher out-of-pocket costs.

Cont. Advantages of HMO’sCont. Advantages of HMO’s

HMO members pay a fixed, prepaid fee (usually paid once a HMO members pay a fixed, prepaid fee (usually paid once a month) for the medical services provided. month) for the medical services provided.

Because of this fixed pre-paid fee it is in the providers best interest Because of this fixed pre-paid fee it is in the providers best interest to make sure that the beneficiaries get basic health care for to make sure that the beneficiaries get basic health care for problems before they become serious. This means that problems before they become serious. This means that beneficiaries get good preventive care through HMO plans. beneficiaries get good preventive care through HMO plans.

High deductibles and coinsurance requirements are usually not High deductibles and coinsurance requirements are usually not emphasized. emphasized.

The big advantage of HMO’s is that there is a huge emphasis on The big advantage of HMO’s is that there is a huge emphasis on controlling costs. controlling costs.

Disadvantages of HMO’sDisadvantages of HMO’s A A big disappointment to many members is that the selection of big disappointment to many members is that the selection of

physicians is usually limited to physicians who are affiliated with the physicians is usually limited to physicians who are affiliated with the HMOHMO

There is a There is a limit to the amount paid for the treatment of alcoholism limit to the amount paid for the treatment of alcoholism and drug addictionand drug addiction and there is now a coinsurance requirement and there is now a coinsurance requirement placed for these treatments by HMO’s.placed for these treatments by HMO’s.

When a beneficiary needs to see a specialist the primary care When a beneficiary needs to see a specialist the primary care physician, must refer the beneficiary outphysician, must refer the beneficiary out

Cont. of DisadvantagesCont. of Disadvantages HMOs also tend to operate in a specific geographical area and HMOs also tend to operate in a specific geographical area and

because HMOs operate in a limited geographical area, there may because HMOs operate in a limited geographical area, there may be limited coverage for treatment received outside the area.be limited coverage for treatment received outside the area. Usually Usually only emergencies are covered. only emergencies are covered.

In an HMO plan beneficiaries often have to wait longer for an In an HMO plan beneficiaries often have to wait longer for an appointment than they would with a fee-for-service plan.appointment than they would with a fee-for-service plan.

Name of HMOName of HMO Care (Staying Care (Staying HealthyHealthy))

Care for Getting Care for Getting BetterBetter

Care for Living Care for Living with Illnesswith Illness

Member Rating Member Rating of Health Planof Health Plan

Aetna Health of Ca. Aetna Health of Ca.

Inc.Inc. XXXX XXXXXX XXXXXX XXXX

Blue Cross HMO Ca. Blue Cross HMO Ca.

CareCare XXXX XXXXXX XXXXXX XXXX

Blue Shield of Blue Shield of California HMOCalifornia HMO XXXX XXXXXX XXXXXX XXXXXXCIGNA HMOCIGNA HMO

XXXX XXXXXX XXXXXX XXXXHealth NetHealth Net

XXXX XXXXXX XXXXXX XXXXXXKaiser Permanente - Kaiser Permanente - NorthNorth XXXXXX XXXXXXXX XXXXXX XXXXXXKaiser Permanente - Kaiser Permanente - SouthSouth XXXXXX XXXXXX XXXX XXXXXXPacifiCare of PacifiCare of CaliforniaCalifornia XX XXXXXX XXXXXX XXXXXXUniversal CareUniversal Care

XX XXXXXX XXXXXX XXXXWestern Health Western Health AdvantageAdvantage

Not willing to reportNot willing to report Not willing to reportNot willing to report Not willing to reportNot willing to report

XXXXXX

X Poor XX Fair XXX Good XXXX Excellent

Dental & Vision coverage under HMO’sDental & Vision coverage under HMO’s

Dental and Vision Coverage under an Dental and Vision Coverage under an HMO plan is usually not through the same HMO plan is usually not through the same provider of the HMO. There is different provider of the HMO. There is different dental and vision providers that sometimes dental and vision providers that sometimes work with HMO’s but operate separately. work with HMO’s but operate separately.

PPOPPO

Preferred Provider Organization (PPO) Preferred Provider Organization (PPO) is a plan that contracts with health care is a plan that contracts with health care providers to provide certain medical services providers to provide certain medical services to its members at a discount fee. A health to its members at a discount fee. A health benefit plan with contracts between the benefit plan with contracts between the sponsor and health care providers to treat sponsor and health care providers to treat plan members. plan members. A PPO can also be a group of health care A PPO can also be a group of health care providers who contract with an insurer to providers who contract with an insurer to treat policyholders according to a treat policyholders according to a predetermined fee schedule. predetermined fee schedule.

PPOPPO

PPOs can range from one hospital and its PPOs can range from one hospital and its practicing physicians that contract with a large practicing physicians that contract with a large employer to a national network of physicians, employer to a national network of physicians, hospitals and labs that contract with insurers hospitals and labs that contract with insurers or employer groups. PPO contracts typically or employer groups. PPO contracts typically provide discounts from standard fees, provide discounts from standard fees, incentives for plan enrollees to use the incentives for plan enrollees to use the contracting providers, and other managed care contracting providers, and other managed care cost containment methods.cost containment methods.

PPOPPO

PPOs can range from one hospital and its PPOs can range from one hospital and its practicing physicians that contract with a large practicing physicians that contract with a large employer to a national network of physicians, employer to a national network of physicians, hospitals and labs that contract with insurers hospitals and labs that contract with insurers or employer groups. or employer groups.

PPO contracts typically provide discounts PPO contracts typically provide discounts from standard fees, incentives for plan from standard fees, incentives for plan enrollees to use the contracting providers, and enrollees to use the contracting providers, and other managed care cost containment other managed care cost containment methods.methods.

History of PPOHistory of PPO

1.1. PPO highlightsPPO highlights PPO insurance is a relatively new type of PPO insurance is a relatively new type of managed care plan. It was developed to managed care plan. It was developed to combine the lower cost of managed care with combine the lower cost of managed care with the great degree of choice found in traditional the great degree of choice found in traditional health care. health care.

According to the American Association of According to the American Association of Preferred Provider Organization, 54 percent of Preferred Provider Organization, 54 percent of all Americans with health insurance now all Americans with health insurance now receive their health care through a preferred receive their health care through a preferred provider organizationprovider organization

History of PPOHistory of PPO

Currently, nearly 112 million individuals are Currently, nearly 112 million individuals are enrolled in a PPO program. This growth has been enrolled in a PPO program. This growth has been primarily the result of the fact that PPOs have primarily the result of the fact that PPOs have delivered exactly what the public has called for zero delivered exactly what the public has called for zero choice, flexibility and a balance between the choice, flexibility and a balance between the delivery of appropriate care and cost control.delivery of appropriate care and cost control.

Latest StudyLatest Study

Over the past few years, PPOs have Over the past few years, PPOs have steadily risen in popularity among steadily risen in popularity among employers and have experienced an employers and have experienced an increase in overall enrollment. According increase in overall enrollment. According to the American Association of Preferred to the American Association of Preferred Provider Organizations, PPO enrollment in Provider Organizations, PPO enrollment in eligible employees rose from 98.3 million eligible employees rose from 98.3 million in 1998 to 106.8 million in 1999. The in 1998 to 106.8 million in 1999. The number of PPO plans operating in the U.S. number of PPO plans operating in the U.S. in 2000 was 1,050, covering over 133 in 2000 was 1,050, covering over 133 million lives.million lives.

Average Employee Costs For Health Care2000-2003*

2000                      2003                     % Increase

Employee Portion of Annual Premium Single Coverage             $334                      $508                          52%

Family Coverage                $1,619                    $2,412                          49%PPO Deductibles

Preferred Provider                   $175                      $275                          57% Non-Preferred Provider         $340                       $561                        65%

Prescription Drug Co-Payments Preferred Drugs                        $13                         $19                         46% Non-Preferred Drugs                 $17                         $29                         71%

Consumers Assessment of Health Plans

Survey (CAHPS) for PPO plans

Percentiles

CompositesN Mean 10th 25th

50th

(Median)

75th 90th

Getting Needed Care - % not a problem 24 88.36 83.08 85.36 89.84 91.78 92.60

Getting Care Quickly - % usually or always

25 83.79 79.37 81.36 84.80 86.63 88.40

Doctor Communicates Well - % usually or always

27 93.19 90.92 92.53 93.36 94.39 94.80

Claims Processing - % usually or always

27 88.27 81.79 86.28 89.01 92.41 94.79

Customer Service - % not a problem 26 69.02 59.09 63.65 68.50 75.17 79.59

Office Staff Helpful and Courteous - % usually or always

27 94.82 93.03 93.47 94.82 95.94 97.06

Advantages of PPOAdvantages of PPO

Patients are not required to use a preferred Patients are not required to use a preferred provider but have freedom of choice every provider but have freedom of choice every time they need care time they need care

Costs are lower if you stay within the Costs are lower if you stay within the network of providersnetwork of providers

The level of benefits is higher for services The level of benefits is higher for services from participating providers from participating providers

Advantages of PPOAdvantages of PPO

The freedom to seek medical care outside The freedom to seek medical care outside the networkthe network

• Payment at 100 percent for most covered Payment at 100 percent for most covered services once you’ve met your out-of-pocket services once you’ve met your out-of-pocket maximum maximum

• No referrals needed or pre authorization for No referrals needed or pre authorization for specialistsspecialists

Disadvantages of PPODisadvantages of PPO

• Co-payments are higher compared to Co-payments are higher compared to HMOs however, some employers HMOs however, some employers and and consumers are willing to sacrifice the consumers are willing to sacrifice the

higher level of cost savings of more higher level of cost savings of more structured managed-care plans for structured managed-care plans for

the the increased flexibility. increased flexibility.

• PPO is generally the most expensive type PPO is generally the most expensive type of managed care planof managed care plan

Disadvantages of PPODisadvantages of PPO

• If patients go outside the network, they will If patients go outside the network, they will have to pay co-payments based on higher have to pay co-payments based on higher charges and they will need to meet the charges and they will need to meet the deductible deductible

• Members can expect paying co-insurance Members can expect paying co-insurance (co-insurance is usually waived and can be (co-insurance is usually waived and can be replaced with a low co-payment.)replaced with a low co-payment.)

Dental coverage under PPODental coverage under PPO

The costs involved in a PPOThe costs involved in a PPO

A define plan with a higher level of coverage if A define plan with a higher level of coverage if services are provided by a preferred provider. services are provided by a preferred provider. Discounts are negotiated and passed on to plan Discounts are negotiated and passed on to plan sponsors. sponsors.

Dental coverage under PPODental coverage under PPO

What specifics are involved What specifics are involved Most managed dental insurance plans Most managed dental insurance plans work under a Preferred Provider work under a Preferred Provider Organization, which means that Organization, which means that

policyholders must choose a primary policyholders must choose a primary dentist from a list of approved dentists. dentist from a list of approved dentists. And to maintain full coverage for all And to maintain full coverage for all procedures, any specialist you see will procedures, any specialist you see will have to be approved by this primary have to be approved by this primary dentist.dentist.

Medical Savings Plan (MSP)Medical Savings Plan (MSP)

History of MSAHistory of MSA

The Health Insurance Portability and Accountability Act (HIPAA) was passed in

Congress and signed by the President in 1996. As a result of this legislation a 4-year pilot program was created. This project was the

Medical Savings Accounts (MSA). It began on January 1, 1997 and was restricted to the self-employed and small groups. The pilot project

was extended until December 31, 2003.

IntroductionIntroduction

The Medical Savings Account or MSA, is a special tax-sheltered personal savings or investment account that is maintained in conjunction with a high-deductible health

insurance policy. The funds in the account may be used for medical services that aren’t covered by the participant’s high deductible

policy.

How it worksHow it works

Instead of purchasing expensive insurance with a low Instead of purchasing expensive insurance with a low deductible and low co-pays, the participant buys a low deductible and low co-pays, the participant buys a low cost insurance policy with a high deductible. The amount cost insurance policy with a high deductible. The amount saved from using the low cost insurance plan is then saved from using the low cost insurance plan is then deposited in a MSA to cover the small bills that aren’t deposited in a MSA to cover the small bills that aren’t covered under the policy.covered under the policy.

The money in the MSA is 100% tax deductible. It can be The money in the MSA is 100% tax deductible. It can be accessed by check or debit card. What ever is not used accessed by check or debit card. What ever is not used for medical expenses will remain in the account and keep for medical expenses will remain in the account and keep growing on a tax-favored basis. It can be used to cover growing on a tax-favored basis. It can be used to cover future medical bills or supplement retirement, in this future medical bills or supplement retirement, in this sense it is similar to an IRA.  sense it is similar to an IRA. 

Advantages of MSA’sAdvantages of MSA’s

Tax deductibleTax deductible Balance can be rolled Balance can be rolled

overover No minimum No minimum

contribution contribution Works with other Works with other

health care coveragehealth care coverage

Disadvantages of MSA’sDisadvantages of MSA’s

Coverage changesCoverage changes

Coverage limitationsCoverage limitations

Restricted MSA planRestricted MSA plan

Other CoverageOther Coverage

Vision Care and MSAVision Care and MSA

Dental Care and MSADental Care and MSA

Employee costs associated with MSA planEmployee costs associated with MSA plan

TYPE OF TYPE OF COVERAGECOVERAGE

DEDUCTIBLE*DEDUCTIBLE* MAXIMUM MSA MAXIMUM MSA DEPOSIT**DEPOSIT**

SINGLESINGLE $1700$1700 $1105$1105

FAMILYFAMILY $2500$2500 $1625$1625

HUSBAND / WIFEHUSBAND / WIFE $3350$3350 $2512.50$2512.50

PARENT + PARENT + CHILDRENCHILDREN

$5050$5050 $3787.50$3787.50

There are no income limits at this time that prevent wealthy people from making tax-deductible contributions to the MSA

and using it as a way to accumulate tax-free earnings on investments.  Therefore, the higher the individual’s tax bracket, the greater the tax benefit an MSA provides.

Although, there is no income limit there is an annual limit to the amount that can be invested.

Breaking NewsBreaking News

President Bush signed the new Health Savings Account legislation on December 8, 2003.  The new HSA have been referred to as the "next generation" of MSA plans. Many aspects of the program remain

the same, however there are some important changes. One of the most significantly and

arguably the most important is that ALMOST EVERYONE qualifies for the new HSA plans!

1. Lower deductibles are available

(1,000 single/2,000 family)

2. Up to 100% of the deductible amount can be contributed to the HAS

**MSA IS NOW HSA**

Key Changes in the new HSA

Point of Service, POSPoint of Service, POSDefinitionDefinition

Offers a full range of health services through a Offers a full range of health services through a combination of HMO and PPO features. Members combination of HMO and PPO features. Members can elect to receive services under the defined can elect to receive services under the defined managed care program or can go outside the managed care program or can go outside the network for care. If patients see a preferred network for care. If patients see a preferred provider, they pay little or nothing. Outside provider, they pay little or nothing. Outside provider care is covered, but at a substantially provider care is covered, but at a substantially higher deductible and co-payments. higher deductible and co-payments.

Introduction to POSIntroduction to POS

The lesser known health care plan that combines The lesser known health care plan that combines the freedom of a PPO and offers the low cost of the freedom of a PPO and offers the low cost of an HMO. an HMO.

When you enroll in a POS you choose your When you enroll in a POS you choose your primary care physician to monitor you health. primary care physician to monitor you health.

This physician has to be within the health care This physician has to be within the health care network and is considered your “point of service”network and is considered your “point of service”

Is built into all managed health care plans and Is built into all managed health care plans and allows the individual the option. allows the individual the option.

Advantages of POSAdvantages of POS

Freedom to choose physicians in network or out of Freedom to choose physicians in network or out of networknetwork

Emergency care coverage is covered no matter where Emergency care coverage is covered no matter where you are in the US or worldwideyou are in the US or worldwide

If you have to relocate temporarily because of a job If you have to relocate temporarily because of a job assignment or a divorce, you will be covered under the assignment or a divorce, you will be covered under the Guest Privileges ProgramGuest Privileges Program

Seeing a physician in network, you do not have to fill out Seeing a physician in network, you do not have to fill out any paper work, co-payments are low & there is no any paper work, co-payments are low & there is no deductibledeductible

Annual out-of-pocket costs are limitedAnnual out-of-pocket costs are limited

Advantages of POS Cont.Advantages of POS Cont.Benefits of the Designated Provider Program

General services In-Network Benefits Out-Of-Network Benefits

Individual annual deductible N/A $300

Family deductible N/A $900

Coinsurance N/A 70%*

Individual out-of-pocket maximum N/A $3,300 (including deductible)

Family out-of-pocket maximum N/A $9,900 (including deductible)

Lifetime maximum Unlimited Unlimited

$10 per visit not coveredSpecialty physician services  

Office Visits $10 per visit 70% coinsurance

Specialist care and consultations

Well-woman exam (one per year) $10 per visit Not covered

Associated medical services  

· Laboratory and x-ray · Allergy testing and treatment · Casting and dressing

No charge 70% coinsurance

Costs of POSCosts of POS

Costs consists of a monthly premium and a Costs consists of a monthly premium and a

co-paymentsco-payments Less than a PPO because the health insurance Less than a PPO because the health insurance

company regulates most of your health carecompany regulates most of your health care Example, if you want to see a specialist, you must get a Example, if you want to see a specialist, you must get a

referral from your primary doctorreferral from your primary doctor If your primary care physician chooses, they will probably If your primary care physician chooses, they will probably

choose from a specialist that works within the networkchoose from a specialist that works within the network These controls reduces the overall cost of a POS health These controls reduces the overall cost of a POS health

insurance planinsurance plan

Disadvantages of POSDisadvantages of POS Seeing specialists may be difficult Seeing specialists may be difficult Referrals to see physicians out of network may become Referrals to see physicians out of network may become

difficultdifficult Hospital visits charges by the physicians are considered Hospital visits charges by the physicians are considered

out of network and charges by the hospital are covered out of network and charges by the hospital are covered in network.in network.

When seeing physician out of networkWhen seeing physician out of network Keep track of all informationKeep track of all information Fill out all necessary paper workFill out all necessary paper work High costsHigh costs Payments of deductibles must be taken care of before coverage Payments of deductibles must be taken care of before coverage

can begincan begin Co-payments are based on usual, customary and reasonable Co-payments are based on usual, customary and reasonable

chargescharges

Vision CareVision Care

In network CoverageIn network Coverage

You can go through the VSP in-network or any You can go through the VSP in-network or any other non-network providerother non-network provider

When making an appointmentWhen making an appointment You must select a VSP providerYou must select a VSP provider Must make sure that it is time for an appointment, you Must make sure that it is time for an appointment, you

can only get one check up a yearcan only get one check up a year If glasses picked are not covered, you pay the full If glasses picked are not covered, you pay the full

differencedifference No annoying forms to fill outNo annoying forms to fill out

Vision Care Cont.Vision Care Cont.Out of Network CoverageOut of Network Coverage

VSP will reimburse you the amount allowed under VSP will reimburse you the amount allowed under your planyour plan

Does not guarantee a full refund or satisfactionDoes not guarantee a full refund or satisfaction You have to mail the billYou have to mail the bill

Must include VSP IDMust include VSP ID Personal informationPersonal information Relationship to the VSP member, if not a memberRelationship to the VSP member, if not a member

Example of Vision Care BenefitsExample of Vision Care Benefits

For this expense

If you use an in-network

provider, you pay...

If you use a non-network

provider, you pay...

An eye exam, costing $65

$0 $40

A pair of lenses, costing $80

$0 $55

You pay $0 $95

The plan pays $145 $50

Cost Savings $95

Dental CareDental Care

Charges are based on reasonable Charges are based on reasonable and customary charges, according and customary charges, according to the Employee Books of Benefits, to the Employee Books of Benefits,

““based on the usual fees charged in your geographic areas based on the usual fees charged in your geographic areas by dentist with similar training and experience and the by dentist with similar training and experience and the insurance company takes into account any unusual insurance company takes into account any unusual circumstances or complications that require special skills, circumstances or complications that require special skills, experience or additional time.”experience or additional time.”

Dental Care Cont. Dental Care Cont.

Types of dental servicesTypes of dental services1.1. Type A: Preventative and diagnostic services, covers Type A: Preventative and diagnostic services, covers

100% expenses and include oral examination 100% expenses and include oral examination

2.2. Type B: Oral Surgery and restorative services, covers Type B: Oral Surgery and restorative services, covers 80% of expenses and includes root canal therapy and 80% of expenses and includes root canal therapy and extractions and oral surgery.extractions and oral surgery.

3.3. Type C: Prosthodontic services. Covers 50% of Type C: Prosthodontic services. Covers 50% of expenses and includes dentures and gold fillings.expenses and includes dentures and gold fillings.

4.4. Type D: Orthodontic services covers children through Type D: Orthodontic services covers children through age 23 and covers braces and surgical extractions.age 23 and covers braces and surgical extractions.

Questions to ask about POS health Questions to ask about POS health insurance insurance

     •   • How many doctors are there to choose from? How many doctors are there to choose from?   • Are doctors in the network private or group practice physicians?   • Are doctors in the network private or group practice physicians?

  • Where are the offices and hospitals in the POS network   • Where are the offices and hospitals in the POS network located? located?   • How are referrals to specialists handled?   • How are referrals to specialists handled?   • What hospitals are available through the plan?   • What hospitals are available through the plan?   • What arrangements does the plan have for emergency care?   • What arrangements does the plan have for emergency care?   • What health care services are covered?   • What health care services are covered?   • What preventive services are covered?   • What preventive services are covered?   • Are there limits on medical treatments or other services?   • Are there limits on medical treatments or other services?   • How much is the health insurance premium?   • How much is the health insurance premium?   • What, if any, are the co-payments for specific services?   • What, if any, are the co-payments for specific services?   • How much more will it cost to use non-network physicians?   • How much more will it cost to use non-network physicians?   • What is the deductible and coinsurance for non-network care?   • What is the deductible and coinsurance for non-network care?   • Is there a out of pocket maximum?   • Is there a out of pocket maximum?

Problems Problems &&

Solutions/SuggestionsSolutions/Suggestions

Problems with HMOProblems with HMO

the primary care the primary care physician are a physician are a "gatekeeper" so "gatekeeper" so you need to get you need to get refers to see a refers to see a specialist this specialist this takes a long time takes a long time so people have to so people have to wait so long to see wait so long to see a specialist. a specialist.

A recommendation A recommendation could be that members could be that members need not go to the need not go to the primary care physician primary care physician but have a group of but have a group of specific specialist that specific specialist that are also affiliated with are also affiliated with the Plan their in to the Plan their in to choose from.choose from.

Problem with MSAProblem with MSA

Information on MSA plans can be hard to findInformation on MSA plans can be hard to find Tax rules concerning MSA are difficult to Tax rules concerning MSA are difficult to

understandunderstand High number of Applications are rejected.High number of Applications are rejected. First year medical problems can be costlyFirst year medical problems can be costly IRS and insurance company have different IRS and insurance company have different

expense approval.expense approval. The issue of tax reliefThe issue of tax relief

Suggestions/SolutionsSuggestions/Solutions Have central website and/or publications that explain the Have central website and/or publications that explain the

planplan IRS and insurance companies work together to sponsor a IRS and insurance companies work together to sponsor a

hotline for MSA/HSA questions and answers. This would hotline for MSA/HSA questions and answers. This would also decrease the amount of rejected applications also decrease the amount of rejected applications

Adding a rider to cover major expenses during the first year Adding a rider to cover major expenses during the first year or two while the account balance is low.or two while the account balance is low.

Each insurer should include a list of expenses the IRS Each insurer should include a list of expenses the IRS covers, so customers can compare to insurance coverage.covers, so customers can compare to insurance coverage.

Proposed neutral tax policyProposed neutral tax policy

Major ProblemMajor Problem The Commerce Department’s Census Bureau The Commerce Department’s Census Bureau

reported in October 2002 reported in October 2002 • The number of people without health insurance rose by 1.4 million, to 41.2 The number of people without health insurance rose by 1.4 million, to 41.2

millionmillion• 15% of the total population in 200315% of the total population in 2003

There are more than 8 million uninsured children There are more than 8 million uninsured children in the United Statesin the United States

Children at risk:Children at risk: 25% of all Hispanic children25% of all Hispanic children 13% of all African-American children13% of all African-American children 14% of all Asian and Pacific Islander children14% of all Asian and Pacific Islander children 7% of all non-Hispanic white children7% of all non-Hispanic white children 20% of all children in low-income families20% of all children in low-income families

Problems Cont.Problems Cont.

New reports indicate that one of every seven Americans New reports indicate that one of every seven Americans is going without healthcare coverage--more than 41 is going without healthcare coverage--more than 41 million of us million of us

Nearly 45 million Americans under the age of 65 without Nearly 45 million Americans under the age of 65 without health insurance health insurance

Malpractice insurance rates are soaringMalpractice insurance rates are soaring Medicaid is becoming a huge burden on state Medicaid is becoming a huge burden on state

governmentsgovernments Increasing unemploymentIncreasing unemployment Baby-boom generation about to flood the Medicare Baby-boom generation about to flood the Medicare

ranksranks

SolutionsSolutions Changing delivery of health care from a Changing delivery of health care from a

physician-driven to an outcome-driven care physician-driven to an outcome-driven care modelmodel

Continue education and infrastructure Continue education and infrastructure developments developments

Offer tax credit or deductions to help offset the Offer tax credit or deductions to help offset the cost of health insurancecost of health insurance

Tax provisions to the low-incomeTax provisions to the low-income Alternative financing for health careAlternative financing for health care

New taxesNew taxes More taxesMore taxes

The The Cancer Detection Programs: Cancer Detection Programs: Every Woman CountsEvery Woman Counts

Gives low-income women access to screening and Gives low-income women access to screening and diagnostic services for breast and cervical cancer. diagnostic services for breast and cervical cancer.

Signed on October 24, 2000Signed on October 24, 2000

Eligibility:Eligibility: Women with income at or below 200 percent of the federal Women with income at or below 200 percent of the federal

poverty level poverty level Age 40 or over for breast cancer screening Age 40 or over for breast cancer screening Age 25 or over for cervical cancer screening Age 25 or over for cervical cancer screening Not covered by Medi-Cal, Medicare, or other health insurance or Not covered by Medi-Cal, Medicare, or other health insurance or

can't afford share of cost (co-payment) can't afford share of cost (co-payment) Must live in California Must live in California

ProposalsProposals

President Bush proposed budget includes a tax-credit President Bush proposed budget includes a tax-credit provision that would give a $1,000 credit to individuals with provision that would give a $1,000 credit to individuals with incomes under $15,000. The tax credit would decrease to incomes under $15,000. The tax credit would decrease to zero when the individual's income reached $30,000. The zero when the individual's income reached $30,000. The president's proposal would give families with incomes up president's proposal would give families with incomes up to $25,000 a tax credit of $1,000 per adult and $500 per to $25,000 a tax credit of $1,000 per adult and $500 per child, up to a maximum of $3,000. child, up to a maximum of $3,000.

The Relief, Equity, Access, and Coverage for Health The Relief, Equity, Access, and Coverage for Health (REACH) Act of 2001 (S.590) proposes tax credits of up to (REACH) Act of 2001 (S.590) proposes tax credits of up to $1,000 for individuals without access to employer-$1,000 for individuals without access to employer-sponsored health insurance and adjusted gross incomes sponsored health insurance and adjusted gross incomes below $35,000 in 2002. Families with incomes below below $35,000 in 2002. Families with incomes below $55,000 would receive tax credits of $2,500. Tax-credit $55,000 would receive tax credits of $2,500. Tax-credit amounts would decline as income increased. amounts would decline as income increased.

Future ProgramsFuture Programs

Expanding coverage through existing public health Expanding coverage through existing public health coverage programs:coverage programs:

Some candidates propose further expansions of these programs to Some candidates propose further expansions of these programs to a broader group of children and adults. In the case of Medicaid and a broader group of children and adults. In the case of Medicaid and SCHIP, proposals to expand coverage to the parents of eligible SCHIP, proposals to expand coverage to the parents of eligible children or including poor, childless adults have been put forward by children or including poor, childless adults have been put forward by some states and are now a part of the national debate. Some some states and are now a part of the national debate. Some policymakers suggest that Medicare can serve as the vehicle for policymakers suggest that Medicare can serve as the vehicle for coverage expansions, especially for the near-elderly, many whom coverage expansions, especially for the near-elderly, many whom increasingly face losing employer-based health coverage and find it increasingly face losing employer-based health coverage and find it difficult or prohibitively expensive to buy health insurance in the difficult or prohibitively expensive to buy health insurance in the private market.private market.

Could reach many low-income peopleCould reach many low-income people

The American Association of University Women (AAUW)

The American Association of University Women (AAUW) supports access to quality health care for all women and their families. Today, 75 percent of privately insured Americans are enrolled in managed care health plans, yet many consumers report widespread problems:

denial of access to medical specialists refusal to pay for emergency room visits lack of information about policies and procedures and arbitrary limits on medical care.

The American Association of University Women (AAUW) Cont.

AAUW believes that Congress should enact enforceable federal standards to assure a minimum level of quality and protections for every consumer covered by private managed care health plans. These standards must address the unique health care needs of women, including reproductive health. Any managed care reform legislation enacted into law should do the following

Improve the accountability of health plans by:

Ensuring that when care is denied or limited, patients have access to adequate legal recourse and a genuinely independent external review of their claim

Allowing individuals to sue their health plan if they are harmed by the failure of their plan to comply with an external reviewer’s decision

Ensuring that women have direct access to ob-gyn services from any obstetrics and gynecological specialist participating in the health plan

Requiring that insurance companies pay for emergency services if a reasonable person would consider the situation an emergency

Guaranteeing access to clinical trials that may save lives

Improve access to health care services for women and their families by: (Cont)

Ensuring that pregnant women can continue to see the same health care provider throughout pregnancy even if their provider leaves their health plan or their employer changes plans

Requiring plans to allow doctors to disclose to patients all available medical options and to advocate on behalf of their patients

Ensuring that managed care plans incorporate gender-specific and pediatric-specific medicine when they develop written clinical review criteria

Requiring that managed care plans provide important information to consumers regarding their health plans’ policies, procedures, benefits, and other requirements

Make sure to consider these before Make sure to consider these before you buy insuranceyou buy insurance

Comparison shop! Comparison shop! Call the California Department of Insurance to verify if the agent and Call the California Department of Insurance to verify if the agent and

the insurer are properly licensed. the insurer are properly licensed. Decide what you need and want before you sit down with the agent. Decide what you need and want before you sit down with the agent. Do not be rushed into buying insurance. Do not be rushed into buying insurance. Set the place, the beginning, and the ending time of your meeting. Set the place, the beginning, and the ending time of your meeting. Get a second opinion before you buy or replace insurance. Get a second opinion before you buy or replace insurance. Do not buy anything you did not intend to purchase or do not want. Do not buy anything you did not intend to purchase or do not want. Do not replace an existing policy unless you can not afford it or the Do not replace an existing policy unless you can not afford it or the

benefits no longer meet your needs. benefits no longer meet your needs. Do not pay cash. Do not pay cash. Do not be intimidated. Do not be intimidated. If you feel unsure or uncomfortable If you feel unsure or uncomfortable DON’T DO ITDON’T DO IT! !

Your Rights in a Group Plan Your Rights in a Group Plan Once an employer health plan is issued, a carrier generally may not use the Once an employer health plan is issued, a carrier generally may not use the

health-related factors of any insured as a basis for canceling or refusing to renew health-related factors of any insured as a basis for canceling or refusing to renew the plan. The health factors may still be used to determine the plan’s premium the plan. The health factors may still be used to determine the plan’s premium rates, however.rates, however.

A carrier may not "cherry pick" individuals within a group to offer or deny coverage A carrier may not "cherry pick" individuals within a group to offer or deny coverage to, nor may a carrier charge different individuals within the group different rates. to, nor may a carrier charge different individuals within the group different rates. When deciding whether to cover a group, the carrier must accept or reject the When deciding whether to cover a group, the carrier must accept or reject the group as a whole.group as a whole.

Large employers establish the criteria to determine employees who are eligible for Large employers establish the criteria to determine employees who are eligible for enrollment. Such criteria may not be based on health factors. A large employer enrollment. Such criteria may not be based on health factors. A large employer carrier must accept or reject the entire group of individuals who meet the carrier must accept or reject the entire group of individuals who meet the participation criteria established by the employer and who choose coverage.participation criteria established by the employer and who choose coverage.

Carriers must allow new employees to have at least 31 days from their start date Carriers must allow new employees to have at least 31 days from their start date to decide to enroll in a plan. Carriers must also offer a 31-day "open enrollment to decide to enroll in a plan. Carriers must also offer a 31-day "open enrollment period" each year, during which any existing employees who are not yet covered period" each year, during which any existing employees who are not yet covered may join. There are special enrollment periods for certain employees and may join. There are special enrollment periods for certain employees and dependents. For example, a dependent for which an employee must provide dependents. For example, a dependent for which an employee must provide medical child support under a court order may be enrolled before the next annual medical child support under a court order may be enrolled before the next annual enrollment period.enrollment period.

Carriers must provide the employer with at least 60 days advance notice before Carriers must provide the employer with at least 60 days advance notice before premium increases take effect, and 90 days notice before discontinuing a plan. If premium increases take effect, and 90 days notice before discontinuing a plan. If a plan is discontinued, the carrier must offer each employer the option to purchase a plan is discontinued, the carrier must offer each employer the option to purchase other employer-sponsored healthother employer-sponsored health

Conclusion Conclusion

For further information on Health Care plans check with For further information on Health Care plans check with the Department of Managed Health Care. the Department of Managed Health Care.

This department offers a lot of information on every This department offers a lot of information on every health plan that is licensed by the Department. health plan that is licensed by the Department.

It can also help resolve problems that participants are It can also help resolve problems that participants are having with their health plan, including issues about having with their health plan, including issues about medical care, prescriptions, preventive testing and mental medical care, prescriptions, preventive testing and mental health services. health services.

In addition assistance is also for complaints and the In addition assistance is also for complaints and the health care rights of the consumer.health care rights of the consumer.