A Publication of WTVP

Women have unique opportunities as healthcare decision-makers. We make contributions to the advancement of quality and cost-effectiveness as vocal advocates of individual needs and the family dynamic and as social innovators. The greater we understand our own healthcare access and the provision of insurance benefits, the more likely we ensure the legacy of world class healthcare so readily enjoyed in this community.

In this article we offer some simple advice on making the most of three popular health coverage models. First, let’s remind ourselves how we got here.

Historically, health insurance was a relatively inexpensive proposition for employers and insurance carriers. Technology, scientific advances and an aging population have contributed to dramatically increasing costs. This is not a revelation to our readers. In order to meet the demand for access to this world-class care, the industry created cost-cutting tools like Preferred Provider Organizations (PPOs) and Health Maintenance Organizations (HMOs). PPOs created focused points of access through networks of healthcare providers which offered discounts on the cost of services. HMOs aimed at reducing costs while improving HEALTHthe quality of care by instituting a means for primary healthcare providers to coordinate care efficiently and effectively.

The most recent trend in improving care and controlling costs is the re-engagement of consumers in healthcare decisions. The primary means of obtaining “consumerism” employs a two-fold approach: Qualified High Deductible Health Plans (QHDHPs) and Internet-based tools for information about healthcare pricing, safety and quality. Much like our purchase of other goods and services, we make better decisions when we have a stake in cost, appropriateness and outcome.

Optimizing Your Type of Insurance Coverage

As the most prevalent form of insurance coverage, PPOs give us choice, offering the greatest access to healthcare providers. Nearly all PPO plans have two levels of benefits. The highest level of coverage is for a network of providers who have agreed to provide services at a discounted cost. A second level of coverage is available for other healthcare providers, but comes at greater personal expense in return for the freedom of choice. Clearly, our best decision is to use the network of preferred providers. It offers the lowest expense for us and the insuring company. Equally important to optimal PPO coverage is the fact that most insurers require a thorough review of the preferred hospitals’ and physicians’ credentials. This includes overall performance, education, safety profiles and state licensing records. Insurers offering these high standards for their preferred providers should offer great comfort as we access healthcare in these types of plans.

To some, HMOs are a more stringent type of coverage which requires the use of a single panel of healthcare providers. These plans provide a single, very generous level of benefits but do not offer lesser coverage for non-network providers. HMO plans are extremely cost-effective for a variety of consumers. We make best use of an HMO policy when we understand the positive results gained by using a primary care physician to coordinate our care. HMOs are also very “women-friendly.” In addition to using a primary care physician for general medical care, HMOs support the use of a primary women’s healthcare provider for those services unique to our gender. Optimizing HMO coverage is achieved best by those of us comfortable with the primary care provider model. That is to say, we must have confidence in our ability to work with one or two healthcare providers as we access needed healthcare. HMO plans are often rated for quality and the effectiveness of their healthcare provider panel. We recommend evaluating these plan choices using nationally recognized rating agencies.

Central Illinois has experienced a steady increase of employers and insurers offering QHDHPs. The coverage under these plans is quite similar to PPO plans in that they often offer benefits under two levels of coverage. The major distinction of a QHDHP is that it requires us to incur a larger amount of personal expense before coverage begins. Often initial expenses must exceed $2,500 to $5,000, or more. This includes medical services and prescription drug expenses. QHDHP’s goals are to aid greater consumerism by engaging us as financial stakeholders and improving our ability to be better shoppers of quality healthcare through self-education. Optimizing a QHDHP first requires a clear buy-in of this philosophy. A more technical way of using these plans to our advantage is to establish a personal Health Savings Account (HSA).

HSAs are medical savings accounts which allow us to set aside the money needed to fund the upfront medical expenses we incur before coverage begins. The funds deposited into these accounts are not subject to personal income tax. Moreover, unused funds may accumulate tax-free year after year to be used for healthcare expenses and premium costs during Medicare-age retirement. QHPHPs and HSAs have more implications than may be fully discussed in this article. Please check with your personal insurance consultant or tax advisor for greater detail.

How can you be most informed about your coverage under a PPO, HMO or QHDHP plan? Our best advice is to read the healthcare coverage documents issued by your employer or insurer. Both state and federal laws require very complete descriptions of how you become eligible for coverage, how to access benefits, how benefits will be paid, what services are covered, your rights when you lose coverage and your rights to appeal certain decisions. Also, the following websites are useful resources related to these topics: