Health Care Model Workgroup Health Insurance Product Comparison

Transcription

1 Model Workgroup Kaiser Foundation Plan Individual Plan (1) s Hospital Educations (Inpatient) (Outpatient) 20 individual visits; 20 group visits transportation Home health ( hour visits) Long term (100 days) Hospice Vision Abuse (Outpatient) Alcohol/ Substance Abuse (Inpatient) Abuse Transitional Eyeglasses Contact lenses Hearing aids Dental (suppleme ntal policy available through Delta Dental) Durable equipment used in the home Personal physician coordinates oversees all treatment, provides for routine urgent needs, monitors preventive health needs, refers member to specialty departments when appropriate. Deductible: $1,500 per year / $3,000 per year per family Out of Pocket Maximum: $1,500 / $3,000 per year per family Lifetime Maximum: None Professional: No charge per visit after deductible Outpatient s: No charge per visit after deductible Hospital (Inpatient): No charge per admission after deductible Emergency ambulance: No charge per trip after deductible. Use Kaiser Facilities exclusively. California Knox Keene health plan product. 1 1 This is likely to be a very expensive plan due to the low out of pocket obligation of the enrollee. Rates not openly published on the Internet. A quote would have to be requested through a broker.

2 Model Workgroup Blue Shield Access+HMO Plan (Individual) (1) s Residential Recovery (60days/CY; 120 days per 5 years) (Emergency) (Urgent) Chiropractic Acupuncture Massage Therapy Hospital Maternity-- (Inpatient) (Outpatient)-- transportation-- Home health-- Long term -- Hospice -- Dental-- Vision Over the counter medication s PCP provides or coordinates PCP arranges for referrals to specialists hospitals Exercising Direct Access to specialists depends s Not Subject to Deductible: Well child visits, scheduled prenatal, vaccines, Chiropractic (20 visits; $15 copay) Acupuncture, Chiropractic, Massage Therapy (25% discount available) Varies widely by service Deductible: $$2,000/$4,000(fa mily) Calendar year copay maximum includes deductible: a limited number of copays do not apply: $3,000 /$6,000 family Professional (MD): $20 Preventive: $20 Provider Network: IPA driven Authorization: Likely to be by decision of PCP IPA Duration of Enrollment: premium payment (this plan is an individual product, not employer-based) California Knox Keene health plan product 2 This HMO product included dental Monthly premium rating tiers are published 2 Copays other out of pocket costs were generally lower in this product than the other HMO product offered to individuals families Page 2

3 Model Workgroup s Abuse (Outpatient)-- Alcohol/ Substance Abuse (Inpatient) (Emergency) (Urgent)-- on policy of PCP s provider group Direct access to gynecology OB/GYN visits Hosp (IP): $250 admit ER: $75 (waived if admitted) Family Planning (counseling): $20 Direct Access to specialists (See previous column): $50 (Hosp): $250 (admit) (OP): $20 DME: 50% Management: Likely to be driven by practices of IPA; no other information found Individual by geographi cal region ( family size) for applicants in good health. Veteran s Administration Hospital-- Maternity (Inpatient) Mental (Outpatient)-- transportation Home health-- Long term -- Hospice -- Abuse(Outpatient)-- Alcohol/ Substance Abortions Gender alteration Invitrofertilization Dental conditional Eye glasses very limited Hearing aids very limited Dental very limited No post- No information on use of a primary physician or provider does not appear to be a key component of VA system. Appears to be s Consumer cost variable based on factors, including income, geography, service related injury : $8 Primary : $15 Preventive : $0 Specialty : $50 No copay for IZ, lab x-ray Long term : $97/day, for 22 nd day + Provider Network:: Veterans Administration facilities Authorization: No information, but likely centralized Duration of Enrollment: Group Size versus Individual Might not offer all the consumer protections of a California Knox Keene health plan product Not a health plan. Page 3

4 Model Workgroup Ambulatory Intensive Caring Unit (A- ICU) Model ( Tech / Dr. Hooper, et. al) s Abuse (Inpatient) (Emergency) Only VA (Urgent)-Only VA Over the Counter medications- Out of country (SCD or VAVRP) Home improvements/struct ural alteration Durable equipment/prostheti cs Chiropractic s could be the same as other health plans ( would have to be if product, integrating the Tech model, is offered under a Knox Keene health plan. However, the difference would be in the delivery model delivery. This could also be structured as a PPO product, in which case, there would natal child [Note: Not enough information to evaluate. However, if developed as a Knox Keene product, any benefit exclusions would have to be allowable under state law regulation. system of manageme nt for servicerelated conditions This model would place true case management responsibility on a specially selected primary his support staff of nurses assistants. Tech model appears to call for reverse copays that is incentive payments to the patient for following certain proscribed regimens. There could be other copays applied for all other non primary preventive services. This delivery model, termed the Ambulatory Intensive Caring Model (A- ICU) focuses mainly on identified high risk persons (would even exclude those with persistent primary diagnosis of mental illness or substance abuse or nonbehavioral chronic illness, such as sever CNS injuries Page 4

5 Model Workgroup s be greater benefit flexibility, yet still be administered by a health plan. This could also be structured as a PPO product, in which case, there would be greater benefit flexibility, yet still be administered by a health plan.] requiring prolongedinstitutionally based ). It is not a plan for a normal population. It proposes to spend additional funds to establish a centrally located delivery infrastructure of physical facilities appropriately trained oriented physicians, nurses, assistants, receptionists, to intervene early intensively to avoid more costly specialty tertiary services. The hypothesis is that an assumed percentage savings from hospital specialty would help to fund upfront development to make greater proportional allocations to primary preventive, though the time horizon for the realization of Page 5

6 Model Workgroup s changes doesn t appear to have demonstrable support yet. The model is advanced by some well-known Bay Area physicians health thinkers. Plan of San Mateo Worx Plan (for IHSS workers) Hospital Maternity (Inpatient) (Outpatient) transportation Home health Long term Hospice -- Abuse (Outpatient)-- Abuse (Inpatient) (Emergency) No over the counter medication s Infertility diagnosis treatment Vision under HPSM eyeglasses contact lenses needed after cataract surgery only; coverage provided Primary physician provides, authorizes, coordinates all health, except for emergencies or out of area urgent IHSS workers pays $10 per month No coinsurance amounts apply. No deductible applies No out-of-pocket maximum applies. Copays vary in application across the range of benefits. With one exception, no service or procedure copay exceeds $5 Physician OP visits (excl. wellchild, prenatal, Provider Network: HPSM network; County Mental System; choice of PCP will be determined by choice of PCP or specialist. Authorization: Primary provider Duration of Enrollment: Employment related Group product California Knox Keene health plan product Page 6

7 Model Workgroup s (Urgent)- Acupuncture Chiropractic Hearing aids Organ transplants Durable Medical Equipment Orthotics/Prosthetics separately through SEIU Dental ly indicated procedures, as defined; coverage provided separately through SEIU etc.): $5 OP(excl. contraceptives): $5 Hospital IP: No copay ER visit: $25 (waived if admitted) Washington Basic Plan Hospital Maternity (Inpatient) (Outpatient)-- transportation Home health Long term Chemical dependency (Outpatient) Plan has waiting periods for preexisting conditions some services (organ transplants ) Maternity prescriptio n drugs excluded PCP chosen by consumer. PCP provides or coordinates. must be received through plan providers. Women may self refer to Premiums are based on age, income, family size, health plan chosen Preventive: No copay Most services: low copays (acc. Program literature) Annual deductible: $150 Coinsurance: 20% some Provider Network: Use health plan s network Authorization: With the exception of emergencies, must be approved by health plan to be covered Duration of 3 [Note: not sure about inclusion of chiropractic acupuncture; some therapies] 3 Might not offer all the consumer protections of a California Knox Keene health plan product Page 7

8 Model Workgroup CalPRIME CalKAT (Halvorson, et al Model (as described in s Chemical dependency (Inpatient) (Emergency) (Urgent)- Organ transplants Durable Medical Equipment Orthotics/Prosthetics The Affairs article does not detail the covered benefits exclusion under the model. Therefore, at this time, it is not possible to identify specific benefits from preexisting conditions Sex change Infertility (incl. Invitro) Eye glasses Hearing aids Speech recreationa l therapy Dental services Weight loss programs Orthopedic shoes routine foot [Note: not enough information to evaluate] plesignated women s health professiona l [Note: not enough information to evaluate] services Annual Out of pocket maximum: $1,500 If consumer changes plan during the year, deductible out of pocket maximum starts over Plan A ($2,000 annual primary benefit) Plan B (Primary +$10,000 deductible + catastrophic coverage) Enrollment: Premium payment Individual plan [Note: not enough information to evaluate] Applies to tax filers legal residents who don t file taxes CalPRIME Page 8

9 Model Workgroup Affairs) [Note: Article focused on high level plan issues, like premium consumer out of pocket participation.] s exclusions, as set forth for other health insurance products. (1) Plans selected on basis of lowest deductible lowest copay option offered Plan C Primary +$2,000 deductible+ catastrophic coverage) Plan D (full coverage, no deductible, some copays) subsidized first dollar basic for low income (<300% FPL) CalCAT self funded, stateadministered, high deductible catastrophic plan for moderate high income persons Page 9