Benefits drive the cost of a health plan, and all plans try to balance benefits and cost. All plans limit payment for non-essential or experimental treatments, job-related expenses, most cosmetic treatment and a range of other "exclusions".
The Unitarian Universalist Association (UUA) plan offers a broad range of benefits including preventive care for adults and children and routine office visits at modest co-pays, plus hospice, midwife services, mental health treatment, and private duty nursing, and prescription drugs, to name only a few examples. Unlike many other plans, it includes voluntary pregnancy terminations, and transgender surgery up to a fixed amount.
To understand benefit details, you will have to do some homework. We've included a worksheet (PDF) to make the analysis easier. Fill in as many of the categories as interest you, and then make your decision. Some people will go no further than the monthly premium and "Is my doctor in the plan?" Others will go a little deeper. If you need help interpreting some part of your coverage choices, you can contact the Health Plan Director at (617) 948-6405. Here are a few terms you will need to know:
- Co-pay. Think of the co-pay as the admission fee for access to a provider. This is the amount the patient pays "up front" at the doctor's office, hospital ER, or when filling a prescription. The co-pay is kept by the provider as part of their payment for providing the service. The co-pay does not count toward the deductible.
- Deductible. A deductible is the amount that a patient is responsible for before the insurance plan accepts responsibility for its share of payments to providers. Deductibles commonly range from $500 to $2,500 or more.
- Coinsurance. After the deductible has been met, this is the percentage that the plan pays of the balance. Many plans apply a deductible and coinsurance, usually 70%, 80%, or 90%, to all services. Some plans, like the standard PPO that the UUA offers, cover some services at 100%, often without a deductible. This is an area where you have to read your coverage documents.
- Out-of-pocket Maximums. Most plans, but not all, limit your financial exposure in a calendar year. The UUA standard PPO, for example, limits your exposure to $5,000 per individual, and $10,000 per family. These limits to a subscriber's financial exposure are often overlooked. Some commercial plans can offer low premiums because the patients assume a very large risk for catastrophic care. (In the insurance world, the word "catastrophic" refers not to the disease but to the high cost of treatment.)
Before you begin, keep in mind some key questions:
- What gets paid at 100%? How much are the co-pays?
- What else is covered, but at less than 100%?
- How much is the deductible?
- What is the coinsurance percent?
- Is there any protection against large out of pocket costs for me in a calendar year? (The UUA plan has both individual and family limits.)
- Does the plan cover prescription drugs? What are the co-pays? Are generics and brand names covered differently?
- What are the exclusions? The big ones to watch for are exclusions for preventive care, pregnancy termination, dental injures, prescription drugs, and treatment for mental illness.
- Does the plan cover pre-existing conditions? Group plans will make some kind of provision for coverage at some point in time. Non-group, or individual, plans can be very restrictive.