Category News

Small Group Rates Delayed 

Every year the health insurance companies of Indiana have to submit their rates and plan designs for approval through the Indiana Department of Insurance. In the past, this filing would be submitted for review and approval in the month of May.  The filing for 2019 small group fully insured policies was extended to the end of June. This extension has also extended when the department of insurance would approve the 2019 rates. 

The main Indiana insurance companies like Anthem and UnitedHealthcare are not sure when rates will be approved. It could be October 15th, or we could end up in the month of November before we have approved rates.

This delay is having large unintended consequences for Jan 1st small group both under the affordable care act and legacy groups!

80%+ of small groups renew Jan 1st.  Under the ACA fully insured market, these plan designs change every year. The plan changes are not just minor, we have seen deductible, co-pays, co-insurance have huge changes that create more cost sharing to the insured. A perfect example was UHC 2018 introduction of a plan that had 50% co-insurance for outpatient services. The plan was advertised as an 80% co-insurance plan but in the details (small print) it was determined outpatient was 50%. This creates a large cost sharing when the out of pocket max is $7,000+.

In a perfect world, a small group should make renewal decision at least 60 days prior to the actual renewal date. Under the ACA, by law small group fully insured renewal rates must be released 90 days in advanced. 

If 2019 rates are not approved until November, Indiana small companies will not have much time to make decisions or even review alternate options. 

Every Insurance agency/broker active in a small group (there is not a lot of us) is going to be overwhelmed with request for proposals and learning the new group insurance policies being offered. 

group insuranceNefouse & Associates Solution for Small Group:

Our solution to the 2019 small group rate delay is both being proactive and utilization of technology. First, it must be determined if the fully insured market is the best option for your company.  If your small group company is relatively young and healthy, then reviewing partially self-funded options may be in your company’s best interest. 

With the bulk businesses renewing for Jan. 1st, technology is becoming the quickest option for enrolling and employee education for small Indiana groups. We offer a benefit admin platform delivers on both the education, installation and new employee on-boarding. We can build out a client’s enrollment platform in less than three hours, with employees reviewing and enrolling in company benefits in less than 24 hours. The platform is customized to the clients’ company with logos and dedicated domain name. This is one of the added services we provide our clients at no additional costs.

Our proactive broker approach is all about dedicating the time to reviewing the plan contracts to advise our clients of the best option. Contract review is difficult during normal business hours and really has to be done after hours, this way there are no distractions. Once reviewed, we ask the carriers for an explanation of the area of uncertainty. The response time to these questions can be long, the carrier rep normally will not answer them as they don’t know or want to take on the liability. If the insurance companies legal must give the answer, it can take over a month. If the summary of the benefit chart does not match up with the plan quote, it may be better to disqualify that plan design as an option. If we (as your broker) do not have access to a certificate of coverage (COC), which we won’t until after the plan is issued, you have to be very cautious on plan election.

For Indiana small group health plans, using a broker like Nefouse & Associates that actually cares is the first decision that has to be made.  If you are a small Indiana business will no employees or less than five, you may be a good candidate. Contact us, and we can provide information on the Jan. 1st 2019 Small Group Rates.

 

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Indiana was one of six states to file a lawsuit against the Affordable Care Act’s health insurance provider fee (HIPF) for State Medicaid plans.

The U.S. District Judge ruled in favor of the plaintiffs, Texas, Indiana, Kansas, Louisiana, Wisconsin & Nebraska’s that the government must pay back $840 Million in Obamacare fees.

What is the Health Insurance Provider Fee?

The HIPF is an annual fee charged to health insurance companies on health insurance premiums. The Patient Protection and Affordable Care Act of 2010 assesses fees on insurance companies that provide fully insured health insurance coverage. 

The fully insured tax/fee is 3% of the total health insurance premium.

Business affected:

  • Individual and small group health insurance plans.
  • Large Group Health plans.
  • Stand- alone, dental & vision plans.
  • Stand-alone, behavioral health, and pharmacy plans.
  • Medicare Advantage plans.
  • Retiree-only plans.
  • Medicare part D prescription plans
  • Taft-Hartley Plans
  • Medicaid and Children’s Health Insurance programs (CHIP). Until recent court ruling!

The purpose of the tax/fee is to help fund federal and start marketplaces/exchange.

The estimated cost is $14 billion a year.

The authors of the ACA & PRACA projected that there was going to be enormous profits for the insurance industry because of the Individual Mandate. Thus, they could tax the industry to fund the law. They also assumed that these profits would create carrier competition.

The reality is the insurance industry passed this cost on to the members, which has led to everyone paying about 3% more to fund health care reform.

The fact that Medicaid plan is now exempt from the ACA tax is a massive blow to the ACA and the funding mechanism.  Indiana alone has over 2 million people on Medicaid, and it’s not clear the government can make up for this loss of funding for the ACA.  $840 Million is a year is just a start, other states will follow and with an estimate of $5.5 billion attributed to the Medicaid tax. 

This is a massive blow to the ACA law, that is has gotten almost no attention!   The funding of Obamacare may have just lost 25% of its funding.  This estimated operating costs for the marketplace is $2.1 billion.

It will be interesting to see if the government adjusts the federally facilitated marketplace. There could be a decision to turn those operations over to a third party. 

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All the health insurance companies that want to participate in Indiana’s small group health insurance has submitted rates & plan designs to the Indiana Department of Insurance for review. These filling are for fully insured groups with less than 50 employees.

As always, it’s going to be an interesting year under the rules and regulations of the Affordable Care Act (ACA).

Under the ACA, small group health insurance plans are changing every year.  This has led to frustration with many Indiana small group employers.  Pre ACA, a company, would purchase a health plan, and that plan did not change until the company chooses to change it.  Now, a company could have a $2,500 deductible silver plan in place, but the renewal is mapping them over to a new Silver plan that has a $4,000 deductible.   It’s difficult for most people to see how a $2,500 deductible silver plan is the same as a $4,000.   

Under the ACA, the insurance company is forced to develop plans that meet an actuarial value that then indicates if they are Bronze, Silver, Gold or Platinum.  That actuarial value changes or is interpreted differently every year. Which leads to plan designs being a change in the small group health insurance.

We can’t put all the blame on the ACA with the forced plan changes in the small group.  I believe that if a carrier has higher claims utilization on certain plan design, they discontinue that plan.

As we review 2019 Indiana’s small group plan submissions, most of the cost information is listed in averages, which does not tell the full story.  If a carrier is introducing new plan designs, it’s difficult to determine what the cost increase or decrease as compared to their prior year’s plans.   When we look at the details, rates are determined by counties.  For example, Boone County could have a rate decrease on all of their Silver plans, while Marion County has a rate increase.   Then each plan design has a different cost, and some carriers will offer seven different silver plans.   The average price does not tell the full story.

2019 Small Group Submission

  • Anthem appears to have an average rate increase of 2.5%.
  • UnitedHealthcare appears to have an average rate increase of 8.14%
  • IU Health Plans seem to have an average rate increase of 7.21%

There are a handful of other companies that have filed, but their small group rates are so high that I don’t think they are worth mentioning. Those companies don’t want to compete in the small group market but submit plans, so should they wish to fight in future years there is less barrio of entry.

Anthem filing has decreased on specific plan designs as high as 9%.  In 2018, Anthem increased the cost of their small group on avg of 17%. That rate increase made them less competitive in the under 50 life market.   For 2019, Anthem is trying to get competitive based on the few small group carriers we have in Indiana.

UnitedHealthcare filling is difficult to read because it appears most of their 2018 small group plan designs will be discontinued.  New plan designs will be introduced, which could be a good thing. Last year, UHC offered plans that created many confusions.  They had Silver plans that 80% coinsurance but had different coinsurance levels for specific procedures like outpatient surgeries.  One had to dig deep into the summary of benefit chart to find these carve-outs.  As with Anthem, specific metallic level plans and counties have a different rate increase, so again the plans must analyze for costs and coverages. 2018 UHC was anywhere from 17%-8% cheaper than Anthem.  This led them to pick up a much more significant market share in Indiana small group.   UHC also offered a true multiple-choice option for the small group. This strategy appealed to a lot of small companies, where their employee had different health insurance needs.   With 8% average rate increase, Anthem & UHC should be comparable from a price standpoint.

IU health plans are the HMO which IU health has ownership in. With their average rate increase, they should be below both UHC & Anthem.  In 2018, IU health plans have cost about 7% less than the competition, but that is for a health plan with access to only IU providers.  Indiana small group employers have shown some reluctance to move to a true HMO. The 7% saving has not been enough.

Under the ACA, we see a reluctance from many carriers to compete for small group business. This lack of competition has led to just a few fully insured options. It’s not usually for a small group to switch back and forth between UHC and Anthem. With network access being similar along with plan designs, a small group should take advantage of saving 7%. This back and forth strategy are simplified by using benefit administration platform, which streamlines the enrollment process with the least amount of employee disruption. 

Indiana along with the rest of the country has seen a considerable influx of level-funded/partially self-funded plans enter the marketplace. These options have created substantial cost saving for small groups that are overall healthy.  Level funded allows a group to get lower health insurance costs by going through underwriting.  Groups with as few as five employees are eligible.  The level funded option on average saves a group around 20%. That savings can be even higher if the group has a high amount of dependent participation.   

2019 will be another challenging year for small group health insurance.  An owner will wont to be proactive with their insurance offering by starting their benefits review at 90 days before the renewal. 

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The Trump administration released its final rule on short-term health insurance.
Short-term health insurance is a policy that is very similar to pre-affordable care act coverage. The plan does not cover preexisting conditions and requires underwriting. If your accepted, the cost is 50%-60% less than an ACA product. These plans are also using traditional PPO networks, which gives greater access to medical providers.

The final rule allows for short-term coverage to be extended up to 36 months. Currently, coverage can be offered up to 90 days. This could be a game changer in the current individual health insurance markets. Even though the final rule states a plan can be offered for 36 months, does not mean that all insurance companies will embrace this. We could see contracts that are guaranteed renewable for 36 months.

There is much criticism that these short-term plans will negatively impact the ACA marketplace. That criticism is valid because if someone is healthy and can obtain a 36-month policy for 50% less, that will be very attractive. Then the ACA pools will lose a portion of the healthy members that help to offset higher utilizers. Thus ACA rates will increase.

Why did the Administration Extend Short Term Plans?

Currently in Indiana and the rest of the country, if you are not eligible for tax credits/subsidies on the marketplace, the premiums are astronomically for most middle-class families. Then add in the limited network access with huge out of pocket maxes, it’s not uncommon for a family to have $17,000 in premium with potentially another $14,000 in out of pocket, that could cost a family $30K a year.

That same family looks at the short term for $7,000 a year with the same out of pocket, given the short term does not provide the same level of coverage or covers pre-existing conditions. If a family is healthy, it’s hard not to entertain the short-term option. That is why the administration extended short-term plans.

Short-term plans are underwritten which is where you have to answer medical questions and can be denied the plan. Most of these policies are now enrolled through web-based applications, which makes for easy enrollment. The insurance companies use a technique called Post Claim Underwriting when you have a claim. This where the insurance reviews your past medical history to determine if the claim was preexisting. If it is a prior condition, the insurance company can and will deny the claim. One of the real problems with Post-claim underwriting is the delay of payment to the medical provider. The insurance company may request all your medical records for the past five years. Even if you are persistent most medical provider will take at least a month to release records. If you get diagnosed with the condition that needs immediate treatment, the delay in payment could prevent an obstacle to continuing treatment.

In 2018, short-term insurance sales exploded in Indiana and the rest of the country. Smaller insurance companies got creative with their product offering. To be compliant with the rules set by the Obama administration, short-term was only good for 90 days, and companies created 3×4 policies that included 4 short-term policies with one application. These created a huge saving for health Indiana families. Now with the new ruling, I would predict that UnitedHealthcare & Humana launch new short policies.

When you start looking to purchase a short-term policy, buyer beware. You need to make sure you know what you are buying. Always look at the last page of the brochure that lists exclusions. With these plans, you may want to consider buying them from a name brand carrier.

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Short Term Health Insurance Final Rule 36 months of coverage

Short-term health insurance is a policy that is very similar to pre-affordable care act coverage.  The plan does not cover preexisting conditions and requires underwriting.  If your accepted, the cost is 50%-60% less than an ACA product. These plans are also using traditional PPO networks, which gives greater access to medical providers.

The final rule allows for short-term coverage to be extended up to 36 months. Currently, coverage can be offered up to 90 days.  This could be a game changer in the current individual health insurance markets.  Even though the final rule states a plan can be offered for 36 months, does not mean that all insurance companies will embrace this. We could see contracts that are guaranteed renewable for 36 months.

There is much criticism that these short-term plans will negatively impact the ACA marketplace. That criticism is valid because if someone is healthy and can obtain a 36-month policy for 50% less, that will be very attractive. Then the ACA pools will lose a portion of the healthy members that help to offset higher utilizers. Thus ACA rates will increase.

Why did the Administration Extend Short Term Plans?

Currently in Indiana and the rest of the country, if you are not eligible for tax credits/subsidies on the marketplace, the premiums are astronomically for most middle-class families.  Then add in the limited network access with huge out of pocket maxes, it’s not uncommon for a family to have $17,000 in premium with potentially another $14,000 in out of pocket, that could cost a family $30K a year.

That same family looks at the short term for $7,000 a year with the same out of pocket, given the short term does not provide the same level of coverage or covers pre-existing conditions. If a family is healthy, it’s hard not to entertain the short-term option.   That is why the administration extended short-term plans.

Short-term plans are underwritten which is where you have to answer medical questions and can be denied the plan.  Most of these policies are now enrolled through web-based applications, which makes for easy enrollment. The insurance companies use a technique called Post Claim Underwriting when you have a claim.  This where the insurance reviews your past medical history to determine if the claim was preexisting. If it is a prior condition, the insurance company can and will deny the claim.  One of the real problems with Post-claim underwriting is the delay of payment to the medical provider.  The insurance company may request all your medical records for the past five years.  Even if you are persistent most medical provider will take at least a month to release records.  If you get diagnosed with the condition that needs immediate treatment, the delay in payment could prevent an obstacle to continuing treatment.

In 2018, short-term insurance sales exploded in Indiana and the rest of the country. Smaller insurance companies got creative with their product offering. To be compliant with the rules set by the Obama administration, short-term was only good for 90 days, and companies created 3×4 policies that included 4 short-term policies with one application.  These created a huge saving for health Indiana families.  Now with the new ruling, I would predict that UnitedHealthcare & Humana launch new short policies.

When you start looking to purchase a short-term policy, buyer beware. You need to make sure you know what you are buying. Always look at the last page of the brochure that lists exclusions.  With these plans, you may want to consider buying them from a name brand carrier.

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The Department of Labor released their final rule on the creations of Association Health plans.

There has been a great deal of criticism and misinformation in the media.   

The DOL final rules provide the guideline for setting up association health plans.  These plans would be governed by both State and Federal guidelines.  The Employee Retirement Income Security Act of 1974 (ERISA) would be just one of the laws that the AHP’s would have to follow.

Small employers could join in an association to purchase a group health insurance plan under as a large group entity.  Previously small employers were unable to do this because they were governed under small group laws. This prevents small employers from being treated as a large employer from a health insurance standpoint.  Under a small group, a company must have at least two employees to be eligible for benefits.  This has created an obstacle for most owners who have no employees.  Under the new AHP guidelines, the working owner with no employees can now be eligible for a group health plan.

In Indiana, we saw a large number of business consultants leave employers and operate as a sole proprietor with no employees. At the beginning of the ACA, there were multiple individual health insurance companies that provided decent coverage at a somewhat fair cost.  This allowed these consultants to operate as self-employed.  We fast forward to 2018, the individual market has collapsed, and the policies left are very expensive with limited network access. Thus, most of the Indiana business consultants have rejoined corporation because of the health benefits.  With a properly formed AHP, Indiana consultants will have the option of returning to be self-employed without a lack of insurance options preventing them.

There has been much criticism about the AHP’s offering limited benefit or being subject to fraud.  The DOL’s final rule clearly states the guidelines the health plans must follow.  The plans will have the ability to limit coverage that has been required by the affordable care act, but it’s a very fine line.   The rule states if an AHP covers one of the essential benefits, it cannot limit that coverage.  The AHP could exclude coverage for one of the essential benefits.  There are still multiple safeguards that the plan must go through to be approved.  The AHP still must meet state guidelines to be approved, and the state is not going to approve a plan that may be questionable coverage.   What could be excluded is pediatric dental & vision which could reduce the cost by 3.5%.   The members of the associations must control the group health plan. This could lead to the members voting on what benefits to cover.  Even with membership control, the state Department of Insurance would still have to approve the plan.

An AHP that operates in multiple states is allowed but only if the association is in a tri-state type of situation. Realistically, let’s say we have an association of Light Bulb distributors located in Evansville Indiana, that association could have members in Missouri, Kentucky & Maybe Illinois or Ohio. In that situation, you could have AHP in multiple states.  If that were to happen, the AHP would have to be approved by multiple Departments of Insurance.   The DOL Final ruling appears to be more favorable to AHPs operating in single states and providing a health plan to certain industries. AHPs are prohibitive of offering blanket coverage to any industry.

The AHP must not be sponsored by an Insurance company.  This means that an insurance company can have little to do with the development of the AHP outside of providing coverage and administration services. This can create a barrier to starting a new AHP. It will take someone that has specific knowledge and experience to launch a new AHP. 

How much savings could an AHP deliver vs. the ACA Market?

This is the big question that as of now there is no answer.  Many variables would impact the cost of an AHP.  For an Indiana AHP to honestly be success full, I think the price should be that of pre-ACA, which would be about 50% less than the current small group and Individual plans. 

Here at Nefouse & Associates, we have decided to explore setting up an association plan for Indiana business consultants.

Contact Us if you are interested.

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The remaining two individual health insurance companies participating in the Indiana market have filed their rate for 2019. We now have two insurance companies offering personal health in 2019.

CareSource and Celtic Insurance Company aka AM Better

The good news is these two companies have decided to continue to offer individual health insurance coverage to Hoosiers.  There was the real concern with the amount of risk that these carriers will pick up with Anthem exiting the individual market in 2018.

The average rate increase for CareSource is 10.2% 

The average rate increase for Celtic aka AM Better is a decrease of 0.50 %

These are the averages; each county is assessed with a different rate.

CareSource has a minimum rate change -7.7% with a Maximum rate increase of 33.6%.

Celtic has a minimum of -15.2% with a Maximum rate increase of 5.4%.

CareSource is going to be available in 79 counties and offering 3 bronze, 6 silvers, & 2 gold plans.

Celtic is going to be available in all 92 Indiana counties offering 1 bronze, 9 silvers, & 1 gold plans.

If you are interested in crunching the details of their filings continue reading.

2017 Ambetter insured 49,522 members on the exchange in Indiana. They collected $210,687,579 in premium and pay out $191,692,232 in claims.

2019 Ambetter project they will cover 39,574 members with projected premiums of $214,239,747 and projected claims $172,934,517, but they anticipate a risk adjustment payment of almost $11 million. After taxes and operating costs, they estimate a 3.89% profit margin.

2017 CareSource insured 34,722 members on the exchange in Indiana.  $167,483,560 in premiums with $163,169,826 in allowed claims.

2019 CareSource is estimating to insure 75,194 members collecting $397,028,890 in premiums with $367,341,867 in projected claims, they estimate $58,850,419 in risk adjustment payment. Operating on a profit margin of 5.38%.

For 2019 both Insurance companies are banking on the risk adjustment payment to be profitable in Indiana.  If there are only two companies left in the individual market for Indiana and both anticipate risk adjustment receivables, who pay these funds?

Rates Per County:

Ambetter is decreasing rates on most of their plan designs except silver in Rating Area 10 which includes Boone, Hamilton, Hendrix, Marion, Morgan, & Shelby County.  Area 10 receiving a 3%-5% rate increase on the one silver plan offerings.

CareSource is rating up almost every county. They are increasing their gold plans costs by 15%-29%, which indicates those plans were underpriced from the start.  With the rest of the counties having an increased, their premiums will be higher than Ambetter.  Which could create a situation that this carrier is not used too?

If they have based their distribution model on being the lowest costing, can they continue to attract preferred risk?  Will they even come close to the estimated 75K members they anticipate insuring?

The fact that both carriers filed rates for 2019 is a positive because there was uncertainty if the companies would continue to participate.  When the ACA was originally launched the CBO predicted that by 2019 Indiana would have almost 1 million members receiving coverage from the marketplace.  It’s fair to say that projection was way off as the two insurance companies left are projecting combined just over 100,000 members.

CareSource and Ambetter are primary Medicaid providers, and they have extended those networks to the individual exchange plans.  It appears that this strategy has the highest chance of success in the individual market.  Other Insurance company’s like Anthem, Humana, UHC, Assurant, IU Health, MDwise etc. left the Indiana individual market because they could not be profitable. 

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Insurer Anthem Strikes Deal for Palliative Care Company Aspire Health

Here is a story that was given very little media attention but is big news for Indiana’s Anthem. Anthem is buying Aspire Healt

h that provides home healthcare services for patients suffering from serious illness. Aspires help patients and family manages symptoms of extreme illness to improve quality of life.

Why is this Important News?
We are now seeing the line between health insurance company and medical providers continue to blur.

Integrated Care
Health insurance companies are expanding their footprint in the medical services, and we should see integrated care become more streamlined. In this model, one event would trigger communications with needed medical services, during treatment, all medical providers would be in contact with one another which should lead to better outcomes and patient experience. This is a positive thing.

Lack of Choice
There would be little incentive for Anthem to contract with other Home Healthcare companies. This could lead to a lack of choice and essentially prevent small businesses from entering the market.

Health Insurance companies are starting to look for additional revenue sources in the healthcare field and that is the one way to control rising healthcare costs. In the next 20 years, we could see where the hospitals & insurers are one. Health insurance will move to the managed care model and that may be a good thing. When it comes to healthcare, maybe we need someone to manage us because the medical system is difficult to navigate.

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Channel 13 WTHR Investigates recently reported on a controversial story about Short-Term Health insurance and asked me to be a part of it being a health care professional.

The story is about a family that had been using short-term health insurance and the women was diagnosed with breast cancer. The policy she had purchased was good for 90 days.  Upon the initial diagnosis, the insurance company denied the claims.  At the end after a formal appeal, hiring an attorney and having channel 13 investigate, the insurance company agreed to pay the claim.

With short-term health insurance, companies will conduct Post-Claim Underwriting. This is the practice of researching previous medical records to determine if the condition had been previously diagnosed or had signs or symptoms. If the company finds evidence that the situation was pre-existing, then they will deny the claim.   One of the issues with Post Claim Underwriting is it delays the process of paying the claims, which can lead to delayed treatment. 

With individual health insurance becoming more and more unaffordable in Indiana, short-term health insurance has become a solution for some.

Guide to short-term policies.

1.    These policies are not for everyone. You need to be in good health, not being treated for any conditions.

2.    Look at the term of the policy. Most policies are for 90 days, but there are new products called 4×3 which provides coverage for 12 months. The 4×3 is four short-term policies but underwritten with one application.  In this arrangement, the policy will restart every 90 days. 

3.    Confirm you are purchasing short-term plan. We are seeing more and more Hoosier who are buying indemnity products thinking they are short-term policies.  The indemnity plan may pay a set amount per claim occurrence which ideally should be purchased in conjunction with a health insurance policy to offset the out of pocket.

4.    Look at the network and confirm that it’s a PPO network and it’s a recognized in your community.

5.    Read the brochure or at least the last page they address exclusions.

6.    Purchase the short-term policy from a local broker. Work with an agent that cares about the products they represent like Nefouse & Associates.

Tony Nefouse

https://www.wthr.com/article/fighting-for-coverage-short-term-health-insurance-may-result-in-long-term-trouble

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group insuranceWe come to the point where you are ready to start reviewing group insurance proposals. Before you start receiving insurance proposals information about your company should be taken into consideration. Employee location has a large impact on what type of plans a company should be entertain. Does the employer have employees in other states, does the employer plan on expanding into other states?

Networks
Most group health insurance plans will have some commercial system. The most common interface is the Preferred Provider Organization (PPO). PPO’s are considered a traditional network that most people are familiar have experience. Anthem Blue Access, UnitedHealthcare has Choice Plus, Aetna Signature, Cigna Open Access, Sagamore Plus, PHCS, Encore would be PPO networks Indiana are familiar. PPO offers large national systems with coverage for out of network providers.

Exclusive Provider Organization (EPO) is a type of network that is becoming more popular. The EPO usually is an extensive national network, but there is no coverage out of the system. Some people do not like the idea of not having out of network coverage. The EPO plan can cost less than a PPO and, in most cases, including most of the local medical providers. The gaps in the network usually come from costly medical facilities that choose not to join networks. A common out of network provider would be a drug rehabilitation center.

Health Maintenance Organization (HMO) provides a limited network of medical providers but could have a more integrated care model where all the medical providers are in communication with one another. In most HMO’s a member must choose a primary care doctor in advance. An HMO should have cost savings vs. the PPO & EPO because the network has more control over cost. Indiana does not have a lot of HMO’s to choose from, IU Health plans are one of the few carriers offering this type of program.

Point of Service (POS) is a hybrid of HMO & PPO plan where you must choose a primary care doctor but may have access to PPO network. All care must go to the primary doctor. UnitedHealthcare has brought these plans back through their Navigate products.

Reference Based Pricing is a health plan that does use negotiated contracting with medical providers but instead confers the claim based on a multiplier of Medicare reimbursement rates. This type of arrangement is significantly cheaper because they remove multiple layers from the health care system. There is a significant risk with a doctor not accepting this type of agreement or balance billing by the provider to the patient.

Multi-State Employers:
If you have employees in multiple states, it’s important to look at a national network. Research the systems access for the out of state employees. Some insurance carriers will have local PPO network with a different national network. Anthem is a perfect example of this with the Blue Access PPO network for Indiana and then the Blue Card network for the rest of country. The HMO model may not be the best option for multi-state employers, and most HMO plans will have employee location requirements to be eligible for the program.

Dental Networks:
Dental networks are very similar to health plans where there are PPO & HMO models. Unlike health plans, PPO dental network may not provide access to most dentists. Dental providers have been reluctant to join dental systems because they do not want to discount their prices. Most dental plans will offer some level of coverage for out of network dentists. The DHMO may offer no coverage out of network but provide significant member savings in the system.

Vision Networks:
Vision network seldom get the attention that health or the dental system will get. This could have to do with the cost of vision is relatively inexpensive vs. other insurance coverages. Vision plans also mimic health network and most plan offer rich benefits in the network and some coverage for out of network.

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