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Benefits and Health Plan Reviews

Hoodles Health Plan Benefits Ranking

Health plan benefits have been on a steady race to the bottom over the last decade and even the new mandated Metallic plans through Health Reform are a long way off from the “glory days” of health insurance in the mid nineties when no deductible plans were the norm (not the rarity).  So how do we go about rating or comparing health plans without resorting to four letter words?  Great question and one that needs clarification for the Hoodles health plan review site in order to help people make educated decisions.  Let’s take a look.

Health plan Benefits is probably the second most important criteria when reviewing a health plan right after price and the two are intimately linked (richer benefits equals higher price, all other things being equal).  It really is the reason we’re purchasing health insurance to begin with.  How will the plan pay out if I get sick or injured and need it.  It’s a combination of doctor office visits, ER, prescriptions, and of course…the bigger picture items such as hospital, diagnostic lab/x-ray, and surgery.  Preventative benefits have become less of a consideration since health reform mandates 100% coverage for most of these benefits.  Maternity is also following this trajectory towards coverage on plans as a standardized benefits.  Other than a gut sense of a plan’s benefits (assuming that you’ve actually needed to use the plan), how do we go about comparing or reviewing a plan’s benefits?  Let’s break down the point points.

The Big (and growing) Bill

How does the health plan treat really big bills?  Think of a $20K surgery which is pretty easy to rack up these days.  Usually, a health plan will address this through a combination of it’s deductible and OOP (out of pocket maximum).  We want to know what the real “out of pocket” is for a very large bill.  This is important.  You may compare two health plans both with $2K deductibles but one has an OOP of $3K while the other has a $5K OOP.  That’s a big difference.  On the latter, you’re out of pocket by another $2K.  The premium difference (or other benefits improvements) but better adequately offset this exposure.  This is really why we buy health insurance to begin with.

What’s Your Copay?

Next, how the plan handles smaller bills such as office visits and prescriptions (which aren’t all that small any more)?  Although the out of pocket risk is smaller on these charges, they’re also more likely to occur.  These are usually addressed with copays.  Brand RX will probably have it’s own deductible so that figures into the calculation.  Are there caps on the number of copays (say 3 office visits per year)?  This needs to figure into our review of health plans as well.

Finally, there’s a gut level sense of whether a plan paid out according to EXPECTATION.  Yes, all health plans are very expensive these days that trend will likely continue as long as health demographics go the way they are going.  Were their surprises when you received the EOB (Explanation of Benefits) from the carrier.  Were you left thinking, “Wow…that didn’t pay anything” or was the claim about what you expected.  Did the negotiated rate (for PPO plans) bring your out of pocket down?  Try not to take out general “this is all just to expensive and a rip off” premium shock out on the benefit side.  We need to help people understand their options relative to other health plans available to them.  Ultimately, this will pressure the carriers to respond to our needs.  It’s really the first time,  a third party of consumers was rating them to employer consumers!   Review Benefits accordingly.

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