Health Insurance

I went to a seminar by a representative from Garnett-Powers in December 09 and here is a summary of what I understand it was all about. I hope it helps post-docs in making decisions about which healthcare plan to choose. The numbers represented here is for individual medical coverage only. For family coverage, or for a complete list of things covered, please check GP website (http://garnett-powers.com/uchicago/).

The healthcare coverage that post-docs held for the year 2009 is changed from UHC PPO to Blue Cross Blue Shield of Illinois (BCBSIL) starting January 1^st, 2010. Post-docs did not have a choice other than a PPO plan for the previous year, but with the BCBSIL, we now can choose between a PPO and a HMO plan for medical insurance. If you did not make any changes, then you are automatically enrolled in the new PPO plan as of January 1st. With the new BCBSIL plan, rates have also gone up (your paycheck will be ~$10 less a month). PPO is more expensive than HMO but only by a couple of dollars and you have the option of choosing.

We will continue to have PPO dental insurance but have the option of PPO or HMO for medical insurance.

HMO vs PPO:

Calendar year deductible: the total amount you pay in a calendar year before the insurance begins paying.

HMO:

If you choose HMO, you have to choose an in-network primary care physician (PCP) and he/she becomes the gatekeeper. You need to go to your PCP for all non-emergency medical related issues. He/she will then refer you to an appropriate specialist, which means a second trip to the doctor’s. You cannot just pick a doctor when you need to see one without seeing your PCP first. One nice thing is that, any doctor in the hospital that’s available that day can be your PCP, even a registered nurse (RN). You can also change your PCP once a month. In HMO plan, if you see an out-of network doctor, you pay it all out of pocket (no benefit at all).

HMO doesn’t have deductibles, so every time you are admitted to a hospital you need to pay $250 until you reach $1500/individual, then you don’t pay anymore and there’s no lifetime max on the benefits received. Co-pay is $10 for routine exams.

PPO:

PPO plan is more flexible than HMO in that you don’t need to see a PCP, you can just pick any doctor you want. Benefits are also greater for in-network doctors, i.e the insurance will cover more if the doctor is within their network, which means less out-of-pocket costs to you. If you see an out-of-network, you’ll pay more out-of pocket.

There’s a $250 yearly deductible, it pays 100% once you satisfy this deductible. This means that max out-of-pocket is $250 but it’s hard to reach that limit unless you get hospitalized and have major surgery. Co-pays do not count towards the deductible. Routine physical exam is $15 co-pay, as well as mental health visits. There is a lifetime max benefit, which is $2 million per individual. This may seem like a high amount, but if you have major accident or get a long-term illness, it’s very easy to reach that limit. There’s no such limit if you have HMO.

Going to the ER is $75 but if you go to an urgent care center the co-pay is $30.

Examples:

HMO doesn’t have deductibles, so every time you are admitted to a hospital (does not include regular exams) you need to pay $250, until you reach the $1500 max out-of pocket (in PPO, once you satisfy the deductible, you are covered %100).

i.e. if you go to a doctor for regular exam (outpatient service):

PPO $15 co-pay, rest is covered 100%

HMO $10 co-pay, rest is covered 100%

If you check into a hospital (inpatient service):

PPO: $250 once and you can check in 5 times a year and don’t pay anything but lifetime max benefit is $2 million.

HMO: $250 every time, until you reach $1500 (6 visits), then you don’t pay anything beyond that. Also, no limit on the benefits received.

U OF CHICAGO IS NOT PART OF HMO!! U of C doctors only take PPO plan, so if you choose HMO you need to go somewhere else.

Also, here’s the downside of seeing a doctor at the U of Chicago. When you see a doctor there, the visit is billed as an outpatient service (that’s the way they do it and they have no intention of changing it). This means that instead of the $15 copay, you are billed your annual deductible (up to $250). But beyond the $250, all future visits are 100% covered. This also means that if you had even only a routine exam, you pay whatever it normally costs if you didn’t have insurance (say $160). The next time you see a doctor for any reason, you pay only $80 and you are fully covered for the rest of the year. So if you see a doctor once or twice a year, you end up with your $160-$250 dollar bill instead of $15 you could have paid if only you went to Northwestern hospital. From what I understand, going to U of C only makes sense if you go to the doctor regularly, such as if you are pregnant or seeing a therapist.