Health

Picking a Health Plan - Example 1

For my ideal health plan, I would like coverage for my spouse and myself. Overall, we are generally healthy people. We try to exercise on a regular basis and we eat diet that is heavily focused on whole grains, fruits and vegetables. Our individual healthcare needs differ in the fact that I require long term preventative and maintenance treatment. In 2009 I was diagnosed with a brain tumor. I underwent a craniotomy had it removed and am currently going in for routine check ups and maintenance. Also My husband has a condition called Gastroesphageal reflux disease aka G.E.R.D. I would like a plan that will not leave us paying a huge amount of money in case, I need to undergo another craniotomy or GammaKnife radiation treatment or in case my husband needs to have surgery for my his GERD. In essence, I would like a plan that covers the major events. Monthly premiums should be in the range of $150 to $250. Because I would like the freedom to choose my physicians out of the network, a PPO plan that does not have a large deductible, requires that I pay minimal or no co-insurance, covers hospital stays (inpatient or outpatient) and has no caps on lifetime maximums would be ideal. Based on the aforementioned criteria, I have found three PPO health plans that I can compare with.

The first plan is through Anthem Blue Cross Clear Protection Plus 5000. The monthly premium is $124. The office visit for primary doctor for the first two office visits, I’d have to pay $40 co-pay, where the deductible (in and out of the network is $10,000 annually), is waived. Then additional office visits, I would have to pay 100% of negotiated fee and then there is a 0% co-insurance after my out-of-pocket maximum is reached. Co-insurance in network is 40% after deductible. Out of network my co-insurance is 40% for inpatient and 0% for outpatient both after the deductible is met. My annual out of pocket limit for family is $17,000 dollars in and out of network (includes deductible). Outpatient surgery and hospitalization is 40% coinsurance after the deductible is reached. This seems a little too much money to pay out of pocket. This plan also allows for out of network coverage, however, if I am out of the country, only emergency care is covered.

The second provider is Blue Shield of California Shield Savings Plan 3500. This plan is also a PPO, but the monthly premium is $172. Although this plan is a little more expensive than the first, it provides better coverage and is still in my budget. The coverage for this plan is the following: no charge for office visit for primary doctor and office visit for specialist (after the deductible for the latter), 0% for co-insurance after the deductible, which is $7,000 annually for families. The annual out of pocket is $10,000 (includes deductible), unlimited lifetime maximum, and there is out of network coverage. When I am out of the country, I am fully covered. Periodic health exam has no charge and my deductible is waived. Emergency room visit is $100 per visit, but waived if admitted. For the first plan, the cost is 40% coinsurance after the deductible plus $100 emergency room co-pay (co-pay waived if admitted). Outpatient lab/x-ray is no charge, while the first plan is 40% coinsurance after deductible. A big plus with this plan is that outpatient surgery and hospitalization is no charge after deductible. However, a disadvantage to this plan is that out of network co-insurance is 50% after deductible and out of network out of pocket limit is $30,000 including deductible for family.

The last plan is also a PPO through Health Net Optimum Advantage HAS NG $4,500 deductible. Monthly cost is $130. This plan is very similar to the second plan in that there is no charge after deductible for office visit for primary doctor/specialist and co-insurance is the same at 0% after deductible. However the annual deductible is $2,000 higher than the second ($9,000). Annual out of pocket limit for family is $9,000 as well. There is no cap on lifetime maximum and as in the first plan with Anthem Blue Cross, out of the country coverage is only for emergency care. Advantages to this plan are that the periodic health exam is covered in full with the deductible waived. For emergency room and outpatient lab/x-ray there is no charge after deductible. This was true the plan with Blue Shield, while Blue Cross required I pay. Other pluses about this plan are that outpatient surgery and hospitalization are of no charge after deductible. Disadvantages for this plan include the out of network coverage. The deductible for out of network is the same as in network, however, the out of network co-insurance is a high 50% and out of network out of pocket maximum is $29,000 for family (includes deductible).

Comparing all three of these plans, the trend is that the lower the monthly premiums, the more the consumer pays during major medical events, such as surgeries and hospitalization. This seemed to be the case with Blue Cross. I am mainly concerned with large medical bills, so this plan will not work for me. I could easily see myself being stuck with medical debts on this plan. With Blue Shield of California and Health Net, it seems more promising. The coverage for big ticket items, such as outpatient surgery and hospitalization seem more reasonable. I would be rest assured that if I had to undergo another craniotomy or if my husband needed surgery for his GERD, we’d be paying no more than $7,000/$9,000, respectively. In the end, I would choose Blue Shield of California as a healthcare provider. I like that the annual deductible is not as high, the emergency room is $100 a visit, but would be waived if I was admitted, compared to HealthNet, which was no charge only after the deductible. Essentially, with Blue Shield of California, I’d be covered wherever my husband and I go, and that’s a huge piece of mind that’s worth paying for.

Works Cited

"State-specific Health Insurance Resources." Affordable Health Insurance - Individual Family and Self-employed. Web. 17 Apr. 2011. <http://www.healthinsurance.org/reload-results.lasso?prodid=200>.