Comparison Family Insurance, Research Paper Example

Family Needs

There are 5 plans for insurance that are available to choose with coverage starting in 30 days. The insurance coverage is important because we need flexibility, low copays and no high deductibles plans. The high-deductible plans are for families that do not have a lot of medical cost during the year (Wharam,2012). The plans choices are Aetna HMO, Anthem BCBS PPO, Kaiser HMO, Humana POS and Coventry HMO. The first question is HMO better than PPO better plans for family’s or does the HMO Plan make families pay more out of pocket (Shin & Moon,2007). These are some difficult choices for my family because the HMO’s and PPO’s have some many of the same features and additional benefits that might work for my family. The healthcare industry has purposely added Point of Service plans that are a combination of HMO, and PPO therefore it’s important to compare each plan side by side to analyze the differences.

However, before we compare the plans choices, we will discuss the family needs for insurance. There are no children to consider so the plans that are geared for children immunization would not be a good plan for us. The plans that have additional immunization benefits are primarily for families that have children (Singer, Davis, Gebremariam & Clark,2012).

The plan must not be restrictive and cutting back on every visit because it has to be pre-approved. The ability to go Out of Network is important because the freedom of choice is our number one priority.  The Out of Network allows our family to continue seeing our favorite specialist or primary physician without having to change. The plan must cover the basic preventative care, yearly checkups, emergency visits without expensive out of pocket expense and the ability to visit any specialist.

Medical Needs

The primary family needs are a plan that will pay for degenerative disc disease treatments. The occupation of the wife is nurse and the husband is a California Highway Patrol Officer. The first primary need for the family is a plan that will cover serious injuries because both policy holders need good coverage in case of injury. The second criteria needed in a health plan is low deductibles that allow our immediate visits for current illnesses. The plan that has high deductibles works cost us money because we have to pay out of pocket until family deductible is met. Another need is low co pays per office visit that are around $15 to $25 per visit is in the budget. In addition, as a police officer a plan that has low copays will encourage my husband to visit the specialist more often than not. The plan must not have hidden copayments. The best example is the need for a colonoscopy for people over 50 however, the physician office performing the procedure found out the insurance coverage only covers 60%. The physician office wants 40% paid up front before the surgery. The healthcare plan must have low family caps for the over deductible before the plan pays our visits at 100%. The Out of Network deduction must be low instead of pricing like a high deductible plan.

Flexible Network Choices

The most important factor is what services will the plan pay for degenerative disc injury and the ability to choose the primary physician or specialist. The need for flexibility with specialist is important because the family needs to be able to use the coverage whenever necessary instead of being limited by the plan choices. The specialist may be limited in certain groups not allowing us to find the closest bone specialist. As a result, we do not want to drive 45 minutes just to find a doctor in a network. The network needs to have physicians that are in close proximity to make the physician office convenient and close to our home location. The flexibility of a plan will make the final decision on which one is the best for my family.

The family has doctors they are already comfortable with and they know our background. It’s important not to start over with a new physician that does not understand our medical history.  The plan must have flexible requirements including the ability to see any specialist without a referral. The referral is real important because many polices will not approved the referral to a specialist who is not a part of the network. The requirement of a referral is waste of time to get approved and the professional jobs of nursing and policy officer do not allow such luxury to spend all day trying to get an appointment and a referral. The pharmacy benefits are important because we have several medications that need to be filled each month. Some of the pharmacy benefits have formulary and non-formulary list of what the coverage will or will not covered. In addition, some of the plans do not offer alternatives to name brand prescriptions. The pharmacy plan must have the main drugs such as Lotrel for high blood pressure medicine on the list. The Lotrel is too high of a prescription to pay without some type of discount and the plan must not exclude medication because it’s not on their formulary list.  Our research found that some HMO and PPO plans had pharmacy co pays of $50.00 and the deductible is so high that we end up paying out of pocket for the whole year. In summary, we need a policy that meets all of our family needs.

Plan Comparisons

We have to choose between 5 plans for insurance which a comparison must be cone to determine which coverage best meets our family situation. The insurance coverage is important because we need flexibility, low copays and no high deductibles plans. The plans choices are Aetna HMO, Anthem BCBS PPO, Kaiser HMO, Humana POS and Coventry HMO. It was necessary to compare health insurance plans because the Health maintenance organizations (HMOs) and preferred provider organizations (PPOs) networks have blended plans. The plans have characteristics of both HMO and PPO that have diverse features(Sneider,2000).

Aetna HMO versus Kaiser HMO

The Aetna HMO plan had limitations to which physicians could be use along with high out of pocket co-pays that is similar to a High-Deductible plan. This plan would not work because there is a need for flexibility to visit any doctor without being limited by the HMO Plan.  The Aetna HMO versus the Kaiser HMO was different because the Kaiser HMO allowed the choice of a keeping your own physician but all other benefits were traditional HMO. These two plans do not meet the needs of our family because the copays are $30.00 per visit and $60 for specialist with a $5000 family deductible that must be met before either Kaiser HMO or Aetna HMO pays. They both had a $1500.00 deductible plan which means that the family would pay for pharmacy benefits out of pocket until exceeded $1500 in pharmacy expense. The Kaiser HMO required referral for any specialist but the specialist had to be on the approved Kaiser HMO provider list. The Kaiser HMO Plan was disguised as a HMO but all the resemblance of a High-Deductible plan. The Kaiser HMO Plan and the Aetna Plan had more similarities than differences however, Aetna HMO resemble the traditional HMO plan.

The exclusions for the HMO plan for both Aetna and Kaiser excluded acupuncture treatment which they considered experimental. This was important because the degenerative disease disc problem has done better with treatment from Acupuncturist. These exclusions mean the family will have to pay out of pocket for any acupuncture services. In addition, the Out of Network benefits will not pay acupuncture only by a case by case situation. Some plans will still pay at least 70% of billed charges or 60% for Out of Network services. Both plans do not meet our family needs because we are limited by which provider we can choose, the pharmacy benefits are too expensive and the copayments for each visit is too high. The deductible is set so high that the family plans basically cannot afford to choose the HMO plans. Consequently, the required referrals for a specialist can only be approved by the HMO for Kaiser and Aetna. The plans do not allow the PCP to refer outside the HMO network. The policyholder has no flexibility to utilize their own family and the HMO plans are too constricting and deductible amounts are expensive. The HMOs are managing the care to the point of patients are not getting the proper care because the referral came too late (Rosenthal, et al.,2006).

Humana POS and Coventry HMO

The Human POS was an excellent plan that has HMO and PPO advantages allowing the family to choice their own providers. The Coventry HMO was slightly different that traditional plans because they allowed the customer to choose a physician outside the HMO network but the Coventry HMO plan would only pay 70% of billed charges and the member would be totally responsible for 30% out of pocket expense. The Humana POS allowed the patient to choose any specialist with just a $25.00 copay and no deductible to be meet for surgical procedures.  In contrast, the Coventry HMO has out of pocket expense such as $980.00 for colonoscopy exam. Coventry has hidden insurance coverage that does not make it work it to choose the Coventry HMO such as deduction for family medical is $7600.00 meaning the family pays first. How many families can afford to pay $7600.00 per year before their medical claims get paid. In addition, the Coventry hospital copayment is $5000.00 co pay for inpatient before the Coventry hospital benefit will pay.  The Humana PPO had very few drawbacks except the copays for each office visit was $35.00, specialist copay was $60.00 and emergency room copay was $350.00. In comparison to all the other plans at this point, the Humana PPO would be the choice because of so many excellent benefits that are member friendly and family friendly as far as cost of Out of Pocket expenses.

Anthem BCBS PPO

Our goal was to choose a plan that would give us the freedom to choose any doctor or specialist within our health local plan network.  Anthem BCBS PPO plan allows the members to choose any physician in or out of their network with the same payment benefits of 80%. The copayments for office visits are $10.00 and the specialist visit is $30.00 and the pharmacy benefits are $5.00 for formulary and $10.00 for non-formulary. The Anthem outpatient benefits are one the best in the country because they provider other services such transportation from the hospital after surgery and teleconsultation physician services. The deductibles for the family is $500 per person and the Out of Network benefits will be paid at 70% regardless of outpatient, inpatient or office visit and specialists. In addition, we verified that the degenerative disc disease is covered without any referrals, we can visit any bone specialist without a referral. The Anthem BCBS PPO plan was our best choice for our family.

The Anthem BCBS PPO has all the benefits that are required to help me and my family received the best care without large deductibles and high copayments. The inpatient visits for the Anthem BCBS PPO has a $400.00 copay regardless of the type of surgery. We found that the plans often have extremely high hospital copayments based on the cost of the procedures. The set limit of $400.00 copay was the best option for my family because the copay is not expensive. This means hospitalization for 1 day for 100 days, the copay for inpatient visit is one-time $400.00. The emergency copayments could be waived if $200 copayment was meet for the year. The was important because as a nurse and a police officer we often see how many times simple accidents can lead to emergency room visits. The Anthem BCBS PPO gives us comfort to know that we can visit the emergency room with large copayments.  The final option that contributed to our decision to choose Anthem BCBS PPO is the option to do mail order prescriptions that would provide 30, 60 or 90-day supply without an additional cost. The mail order prescriptions benefit for Anthem BCBS PPO members. The family has several different prescriptions that are normally expensive that we can now get for $10.00 per prescription for 90-day supply.

Anthem BCBS PPO pharmacy has the largest selection of participating pharmacies such as CVS, Walgreens, Walmart, to name a few. This was a convenience for my family to have some many different vendors that accepts the BCBS PPO Pharmacy benefits. The difference between Anthem BCBS PPO and the other 4 plans is the pharmacy benefits are transparent with no hidden cost. In addition, Anthem BCBS PPO pharmacy benefits with provide prescription support if the drug is not on their formulary list. The flexibility of BCBS PPO pharmacy is one the reason we made the choice because medications can be expensive, if the drug is not on the insurance companies formulary list. The out of pocket expenses of non-formulary drugs prices have become so expensive that some families go without medicine because they cannot afford the prescription. Anthem BCBS PPO gives my family peace of mind that the coverage will be there when we need it during a possible catastrophic illness.

References

Rosenthal, M. B., PhD., Landon, Bruce E, M.D., M.B.A., Normand, S. T., PhD., Frank, R. G., PhD., & Epstein, A. M., M.D. (2006). Pay for performance in commercial HMOs. The New England Journal of Medicine, 355(18), 1895-902. Retrieved from http://search.proquest.com/docview/223919861?accountid=34899

Sneider, J. (2000). Family health plan talks spawn new HMO options. The Business Journal, 17 (44), 1. Retrieved from http://search.proquest.com/docview/222340985?accountid=34899

Shin, J., & Moon, S. (2007). Do HMO plans reduce health care expenditure in the private sector? Economic Inquiry, 45(1), 82-99. Retrieved from http://search.proquest.com/docview/200915322?accountid=34899

Singer, D. C., Davis, M. M., Gebremariam, A., & Clark, S. J. (2012). Underinsurance for recently recommended vaccines in private health plans. Journal of Community Health, 37(6), 1164-7. doi:http://dx.doi.org/10.1007/s10900-012-9567-7

Wharam, J. F., Graves, A. J., Zhang, F., Soumerai, S. B., Ross-degnan, D., & Landon, B. E. (2012). Two-year trends in cancer screening among low socioeconomic status women in an HMO-based high-deductible health plan. Journal of General Internal Medicine, 27 (9), 1112-9. doi:http://dx.doi.org/10.1007/s11606-012-2057-x