July 1st, 2002
MANY LARGE EMPLOYERS offer their employees a choice of health insurance plans, usually without consideration of health status or any preexisting health conditions. While available health plans are similar in the benefits offered, they differ in other respects, including health provider choice, access rules, and member cost-sharing requirements. Deciding which type of health plan will best serve immediate and potential health care needs is difficult, particularly for those living with an unpredictable chronic illness like multiple sclerosis (MS).
Preferred provider organization (PPO) plans contract with physicians, hospitals, dentists, and other health care professionals that agree to discount their fees for PPO members. After meeting an annual insurance deductible payment, PPO members pay a coinsurance or copayment amount each time they access insured medical services.
Some PPOs use copayments for use of PPO-- preferred (in-network) provider care, and coinsurance for nonpreferred (out-of-network) provider care. In this way, members have a financial incentive to seek care from the PPO plan's preferred providers because paying a flat fee is generally more affordable than paying a percent of the total charge. Additionally, members who choose nonpreferred providers are responsible for the portion of a non-PPO provider fee above the PPO reimbursement amount for a given medical service.
PPOs offer largely unfettered member choice of medical providers. PPOs have been criticized for fostering episodic care (treating an individual once they are sick) rather than a coordinated approach to preventive health care and disease management.
Questions for evaluating PPO plans include:
* Does the PPO require coinsurance or copayments?
* Are there increased deductible or coinsurance requirements for nonpreferred provider services?
* What are the PPO stop-loss provisions?
* How current is the PPO provider list? Does it include providers experienced in MS treatment? (This information can be obtained from local MS societies and MS community groups.)
* Are the providers on the list located near hospitals, pharmacies, and other providers?
* What other medically related and health promotion services does the PPO provide?
Health Maintenance Organizations
Health maintenance organizations (HMOs) provide members with a predetermined medical care benefit package delivered by a defined panel of staff or contracted medical providers. While some HMOs are national in scope, most are limited to defined geographic coverage areas. HMOs don't require deductibles or coinsurance. They do require member copayments for each use of plan benefits.
HMOs emphasize preventive care. As such, they often provide ancillary benefits like free flu shots, exercise and stress avoidance programs, and free wellness information mailings. HMOs require members to select a primary care provider, who serves general patient care needs and refers patients to specialty care. HMOs are successful at providing a coordinated system of quality health care services at relatively low cost. A common criticism of HMOs is that they have a financial incentive to withhold expensive treatments, normally don't provide insurance benefits for care received without a primary care physician referral (exceptions to preapproval requirements for emergency and urgent care often have specific rules and reporting timelines), and restrict member choice of providers.
Questions for evaluating HMOs include the following:
* What is the HMO's policy on standing specialist referrals for continuing treatment of chronic illness?
* Can referrals be obtained by telephone rather than making an office appointment?
* Can one choose a specialist provider to serve as a primary care physician?
* Does the HMO offer providers experienced in MS treatment? (This information can be obtained from local MS societies and MS community groups.)
* If no MS specialized clinician is available, does the HMO grant out-of-plan referrals for this care?
* What is the policy on reimbursement of nonHMO urgent, emergency, or out-of-area care?
Point of Service
A recent variation of the HMO managed care approach, the point of service (POS) plan permits members to choose the point at which care begins. POS plans divide services along a continuum of access points. Like in an HMO, POS members select a primary care provider to serve their general care needs and provide referrals to specialized care. Contrary to most HMOs, however, POS plans allow members to make appointments with plan-affiliated or nonaffiliated specialists without first obtaining referrals. These in-plan and out-of-plan self-referrals come at increased member costs. A self-referral to a plan specialist might double or triple a member's copayment while a self-referral to a nonplan specialist might introduce member deductible and coinsurance requirements.
Questions for evaluating POS plans include the following:
* What are the POS plan's stop-loss provisions?
* Does the POS plan include providers experienced in MS treatment? (This information can be obtained from local MS societies and MS community groups.)
* What preventive and wellness services are available through the POS plan?
* What is the plan's policy on standing specialist referrals for continuing treatment of chronic illness?
* Does the POS plan have providers experienced in MS treatment? (This information can be obtained from local MS societies and MS community groups.)
* Can one choose a specialist to serve as a primary care provider?
General Health Plan Choice Considerations
Regardless of the plan type, people living with MS or other chronic medical conditions should be attentive to the following before choosing a health plan.
* Are any plan benefits subject to preexisting condition limitations?
* What is the coverage for medical devices, including electric carts, powered wheelchairs, walkers, and canes? What are the procedures for obtaining these benefits?
* What is the coverage for prescription drugs and medical services, such as physical and occupational therapy, acupuncture, chiropractor care, or speech therapy?
* What is the plan benefit maximum?
* What are the plan grievance procedures and policies?
Before making a health plan choice, it's important to list your current
health care needs and how those needs might change in the future. Evaluate
how well the different types of plans meet your needs on each criteria
you have on your list. As a final check, review the specific benefits,
rules, and costs of the plan you choose with loved ones and your workplace
© 2002 Real Living with Multiple Sclerosis