Personal health insurance plans

Dave Zweifel, The Capital Times (Madison, WI)

Here's another one to remember when someone tells you that our "private" health care system works:

The Wall Street Journal ran a front-page story last week with the headline that said it all: "As Patients, Doctors Feel Pinch, Insurer's CEO Makes a Billion."

The story, datelined Minnetonka, Minn., was about William McGuire, a doctor who stopped practicing in 1986 to take a management job with UnitedHealth Group Inc., one of the largest HMOs in the country.

He's now the chief executive officer of the corporation, makes $8 million a year in salary plus bonus, has personal use of the company's private jet and has amassed what the Journal describes as "one of the largest stock options fortunes of all time."

According to the newspaper, those options total $1.6 billion.

"Even celebrated CEOs such as General Electric Co.'s Jack Welch or International Business Machines Corp.'s Louis Gerstner never were granted so much during their time at the top," the WSJ story said.

But the gist of the story is that while McGuire and other UnitedHealth execs are raking in millions, their company is putting the squeeze on everyone else.

"Dr. McGuire's story shows how an elite group of companies is getting rich from the nation's fraying health care system," the bible of the business world reported. "Many of them aren't discovering drugs or treating patients. They're middlemen who process the paperwork, fill the pill bottles and otherwise connect the pieces of a $2 trillion industry."

The newspaper's research shows that UnitedHealth has particularly benefited in recent years as health care inflation eased somewhat.

Insurers still raised premiums at double-digit rates. At UnitedHealth, for example, its stock price tripled from January of 2003 to January of this year and its net income rose to $3.3 billion. Hence, the nice board-of-director-approved windfall for McGuire. (Interestingly, former UW-Madison Chancellor Donna Shalala is a member of UnitedHealth's board.)

"In Minnesota, such riches have infuriated some people," the story continued. "Joel Albers, a Minneapolis pharmacist, regularly impersonates Dr. McGuire at state fairs, donning a tuxedo, holding up an enlarged picture of Dr. McGuire on a stick and handing out leaflets denouncing corporate greed."

Of course, this is just one more anecdote that serves to describe our broken health care system, which leaves more than 40 million Americans without coverage and an embarrassment of riches for those who know how to milk that system.

On one hand we have Medicare, which provides universal single-payer coverage to all Americans over age 65 at about a 2 percent administrative cost. On the other hand we have a hodge-podge of plans with layer after administrative layer that gobbles up close to 20 percent in overhead costs (Dr. McGuire's just a piece of that) and leaves millions out in the cold.

How hard can it be to choose in which direction we need to go?

Dave Zweifel is editor of The Capital Times. E-mail: [email protected]

Copyright 2006 The Capital Times

Source: The Capital Times (Madison, WI)
http://www.madison.com/tct/opinion/column/index.php?ntid=81491&ntpid=0

Terminology

• HMO (Health Maintenance Organization). A health insurance plan or organization that provides a wide range of comprehensive healthcare services through a network of doctors, hospitals, labs, etc. who agree to provide services to HMO members at a pre-negotiated rate. As a member of an HMO, you will need to see your primary care physician for care or a referral to a specialist, except in case of emergency. Your choice of doctors is often restricted to those in the network. As an HMO member, if you don't use the healthcare providers that participate in your plan's network, you will usually bear the full cost of these services.
• Indemnity. A health insurance plan that reimburses the member or healthcare provider at a certain percentage of charges for services rendered, often after a deductible has been satisfied. Indemnity plans typically place no restrictions on which providers a member may visit for healthcare services. Indemnity plans are also referred to as "fee-for-service" plans. They offer great freedom in choosing your healthcare provider, but may involve more paperwork and out-of-pocket expenses for the member.
• POS (Point-of-Service). A type of managed care health insurance plan. Benefit levels vary depending on whether you receive your care in or out of the health insurance company's network of providers. POS plans combine elements of both HMO and PPO plans. As a member of a POS plan, you will likely be required to designate a primary care physician who will then make referrals to network specialists when needed. You may receive care from non-network providers but with greater out-of-pocket costs. With a POS plan, you may be responsible for co-payments, coinsurance and an annual deductible.
• PPO (Preferred Provider Organization).
• A type of managed care health insurance plan that allows you, as a member, to visit whatever in-network physician or healthcare provider you wish without first requiring a referral from a primary care physician. Services will typically be covered at a higher benefit level when rendered by a network provider. As a member of a PPO plan, you will not be required to choose a primary care physician, but may self-refer to specialists of your choice. PPO plans may require co-payments or coinsurance and almost always require that you pay an annual deductible before coverage begins.
• EPO (Exclusive Provider Organization). An EPO is a Exclusive Provider Organization. As a member of an EPO, you can use the doctors and hospitals within the EPO network, but cannot go outside of the network for care. There are no out-of-network benefits.
• Network. A network of physicians, hospitals, and other health care providers that have agreed to provide medical services to a health insurance plan's members at discounted costs. While the health plan's members are free to use any health care provider, the cost to use network providers is less than using non-network providers.

State sponsored plans

 NJ 4-H: Get Moving - Get Healthy

NYC

Health Insurance Information For New York Consumers

If you do not have insurance and you or your spouse is currently working or has recently worked and your employer does not offer insurance or you are self-employed and meet certain critieria, you may be eligible for the Healthy New York program. For more information on Healthy New York, select this link.

Eligibility

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Individuals

Healthy New York

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Call us toll free at 1-866-HEALTHY NY (1-866-432-5849)

Pre-Existing Condition Limitation

Coverage under the Healthy NY program is subject to a pre-existing condition waiting period. This means that if the applicant has a medical condition that they have been either diagnosed with or treated for in the last six months, services for the treatment of that condition may be excluded from coverage for up to a year.

However:

• If an applicant has had prior health insurance coverage and has not had a break in coverage that is longer than 63 days, the pre-existing condition limitation waiting period will be reduced or waived.
• Coverage for other services will still be available for all other covered conditions.

Tradition PLUS Hospital covers hospital only.  $137

Direct HMO/POS $887.85

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Last modified: March, 12, 2019