Get documents about "Medical Plan Comparison Chart
Document Sample
Medical Plan Comparison Chart
UC offers five types of medical plans:
• health maintenance organization (HMO)
• Health Reimbursement Account (HRA) with preferred provider organization (PPO)
• point-of-service plan (POS)
• preferred provider organization (PPO)
• fee-for-service (or indemnity) plan
Each type of plan is described briefly below.
Fee-for-Service
TYPE OF PLAN HMO* HRA with PPO POS PPO
(Indemnity Plan)
Definition Health Maintenance Health Point-of-Service Plan Preferred Provider Traditional Fee-for-
Organization (Health Net, Reimbursement (Blue Cross PLUS) Organization (Blue Service Plan (Core)
Kaiser, WHA) Account with Cross PPO)
Preferred Provider
Organization (CIGNA
Choice Fund)
Reasons People Least costly overall. Focus Greater choice of Greater choice of Broader network of No limits on access to
Choose This on preventative care; no providers; up-front medical providers than providers than HMO or providers; desire to
Type of Plan deductible or coinsurance dollars from an an HMO; ability to go POS; worldwide self-insure a larger part
balance. employer-funded HRA outside the network for coverage available. of front-end cost (high
to help pay eligible care (at a higher cost). deductible).
medical and
prescription drug
expenses
Page 1 of 3
Fee-for-Service
TYPE OF PLAN HMO* HRA with PPO POS PPO
(Indemnity Plan)
Choice of You choose a Primary Care You may see any You choose a PCP; you Two benefits levels: in- Unrestricted access to
Providers Physician (PCP) or a doctor or specialist pay less if you use a network (IN) and out-of- any provider (see
primary care group from the you choose; however network provider. (see network (OON). IN works "Cost Sharing for
network. Both your primary costs for in-network "Cost Sharing for like an HMO. OON-you Services" below).
and specialty care are providers may be Services" below). may choose any
through your chosen lower. provider, but you pay
PCP/medical group. more of the costs (see
"Cost Sharing for
Service" below).
Provider Providers and medical Providers contracted Providers and medical Providers contracted No Network.
Relationships groups are contracted through network may groups are contracted through the PPO
through the HMO network. offer services at less through the POS network. Offers services
cost than out-of- network for IN; OON at less cost than non-
network providers. has no network. PPO.
Primary Care Care is coordinated by a No PCP required. IN-care is coordinated No PCP required. No PCP required.
PCP. by a PCP; OON has no
network.
Specialty Care Your PCP authorizes You may self-refer to IN-your PCP authorizes You may self-refer to You self-refer to any
referrals to specialists. providers in or out of referrals. OON-you may providers in or out of provider.
the network. self-refer. network.
Networks Plan networks are limited, Networks tend to be IN is similar to an HMO Networks tend to be No network.
especially in rural areas. wider than HMO network. OON has no wider than HMO
networks. Plans often network. networks. Plans often
have nationwide have nationwide
networks. networks.
In-Area Coverage You must receive services Services from a You must receive You must receive No restriction.
from a network provider. network provider may services from a network services from a network
be less expensive. provider to have provider to have
coverage at the IN coverage at the highest
benefit level; OON has level in the plan.
no requirement.
Page 2 of 3
Fee-for-Service
TYPE OF PLAN HMO* HRA with PPO POS PPO
(Indemnity Plan)
Out-of-Network You are only covered for Services from an out- For services outside the For services outside the No restriction.
Coverage emergency services. of-network provider network, you pay a network, you pay a
are generally more deductible and share deductible and share
expensive. more of the cost. more of the cost.
Medical Plan Costs Lowest employee costs Usually a little higher More expensive than an Usually the most Lowest premium due
(except for Core). than an HMO. HMO. expensive. to plan design (high
deductible,
catastrophic
coverage).
Cost Sharing for Co-payments for services; Full costs paid from IN-higher co-payments Annual deductibles; Coinsurance coverage
Services (co- no deductibles or employer-funded HRA for services than HMO; coinsurance payments after high annual
payment = flat coinsurance. first, then by member OON-deductibles and lower for network deductible is satisfied.
dollar cost; up to annual co-insurance. providers; higher for non-
coinsurance = % deductible; network providers.
of total cost) coinsurance after
deductible is satisfied
Out-of-Pocket Yes Yes Yes Yes Yes
Maximum
Claims No claims, but Typically, network IN-like an HMO. OON- For PPO providers, no You file claims for
preauthorization required for providers file the you file claims for partial claims to file. You file partial payment of
some services (see plan claim. You file claims payment of costs after claims for non-PPO costs after deductible
details). for out-of-network deductible is satisfied. providers. is satisfied.
providers.
Prescription Typically, a card program Typically, a card Typically, a card Typically, a card program No formulary;
with a formulary and program with co- program with a with a formulary and prescriptions covered
different co-payments for insurance based upon formulary and different different co-payments for on straight percentage
generic, brand name, and in or out-of-network co-payments for generic, brand name, and reimbursement with no
non-formulary drugs. pharmacies. Mail generic, brand name, non-formulary drugs. discounts. No mail
Usually has a mail-order order program and non-formulary Usually has a mail-order order program.
program for maintenance available. drugs. Usually has a program for maintenance
drugs. mail-order program for drugs.
maintenance drugs.
*Kaiser Permanente-California HMO services are only provided through Kaiser facilities.
Page 3 of 3
Related docs
