It’s
no secret; the employee deductions for our QualCare Plus plan will be
increasing dramatically for 2015. We have developed this blog post to help you
better understand the differences and similarities between both plans that we
offer through Children’s Specialized Hospital. Below you will see some of the
common questions regarding our benefits for 2015.
How come QualCare raised the
rate?
This
is a very popular question. We purchase access to the QualCare network each
year. This means we are able to use their network of doctors and get the
discounted rates that they are contracted with those doctors. However, we
(Children’s Specialized Hospital) are self-insured and pay dollar for dollar
for the cost of care for our employees. QualCare is not responsible for the
increase in cost. The increase is beyond our control and driven by the overall
increase in the cost of health care. We
continue to work with QualCare to offer two great plans for you to choose from,
to give you an option that best meets the needs of your family.
Why is only the Plus plan
increasing?
The
vast majority of the costs reside in the Plus plan, and therefore all of our
increased costs have been pushed to the Plus plan in order to keep the Core
plan – a
very rich plan – at an affordable rate. The Plus plan is considered a “buy-up
plan” – you pay a higher rate for the peace of mind that you are paying now in
case you want to limit your out-of-pocket expenses at time of service.
Regardless of if you need to use the benefits provided by the Plus plan, you
are paying for them with each pay check.
Why are you
suggesting we all chose the Core Plan?
We are not trying to “bully” anyone with this recent
increase, as suggested in a recent question submitted through our Intranet
forum. In fact, many organizations offer only one benefits plan to their
employees. We are giving you the option of two plans that offer essentially the
same coverage, and helping you make the best decision for you and your family. The
only benefit covered in the Plus plan that is not covered in the Core plan is
vision. All other benefits covered in the Plus plan are covered in the Core
plan.
False: The doctors
between the two plans are different.
One of the common misconceptions I’ve heard is that your
doctor won’t be covered if you switch plans. That’s incorrect. You can visit
the same doctors regardless of if you are in the Core or the Plus plan. As long
as your doctor accepts QualCare POS insurance, your doctor is considered
in-network.
If you choose to visit a doctor who is out-of-network, you
have the same out-of-network benefits between the two plans and are responsible
for the same out-of-pocket maximum. The only difference between the Core and
Plus plan in regards to out-of-network doctors is you are required to pay 10%
more of your coinsurance fees if you are in the Core plan than if you are in
the Plus plan. Just 10% more! In the grand scheme of things, that
difference is minor compared to your total expense throughout the year.
Let’s break it down
*This comparison compares both plans for an employee who
makes less than $30,000 per year and is enrolled in an individual plan who only
visits an in-network provider.
QualCare Core Plan
|
QualCare Plus Plan
|
|
Deductions in each paycheck
|
$15.52
|
$125.70
|
Deductible
|
$500
|
None
|
Coinsurance
|
Plan pays 80%
|
Plan pays 100%
|
Out-of-pocket max
|
$2,000
|
$2,000
|
Copay
|
$15 PCP
$15 Specialist |
$15 PCP
$15 Specialist |
Some key terms you’ll need to know while we go over this
chart are:
- Deductible: Amount a member pays for care before the plan begins to cover expenses
- Copay: Member cost for routine services
- Coinsurance: The percentage of costs a member must pay for care after the deductible has been met.
- Out-of-Pocket Maximum: The absolute maximum amount you’ll pay annually. Your medical copays, deductible and coinsurance responsibilities will accumulate toward the plan’s out-of-pocket maximum.
If you are in the
core plan:
- You’re contributions to your benefits over the entire 2015 year will be: $403.50
- In order for your insurance to begin paying for 80% of the services you need (coinsurance), you are required to pay $500 yourself (deductible)
- In order for your insurance to pay 100% of the services you need, you must first pay $2,000 out of pocket (out-of-pocket max)
- This includes all copays, deductible, and coinsurance responsibilities
- The total amount that you’d have to pay throughout the year (your out-of-pocket max [including your copays] + your contributions) before every doctor’s visit and service is covered 100% would be $2,403.50
If you are in the
Plus plan:
- You’re contributions to your benefits over the entire 2015 year will be: $3,268.20
- You do not need to meet a deductible for your insurance to begin paying 100% of the services you need (not inclusive of copays)
- In order for your insurance to pay 100% of your services (in this case, your copays only), you must first pay $2,000 out of pocket (out-of-pocket max)
- This means you are responsible for $2,000 in copays before they are paid for by your insurance
- The total amount that you’d have to pay throughout the year (your out-of-pocket max [in this plan, only your copays] + your contributions) before every doctors visit would be covered 100% would be $5,268.20
We refer to the Plus plan as our “buy-up” plan. It gives you
the peace of mind knowing that you have a set fee that comes out of each
paycheck, and the only thing you’ll be responsible for should you ever have any
unexpected healthcare need is your copay (as long as you stay in network).
The Core plan is referred to our basic plan, but is still a
very rich plan – it is more affordable, but still offers great coverage. The
Core plan requires you to plan yourself, do some of the guess work on your own.
You’ll have to reach a certain amount of expenses from your own pocket before
you have the luxury of leaving the guesswork to the insurance company.
In fact, we offer a program called Flexible Spending Account
that helps you to plan for those unplanned expenses.
If you look at the information I just shared with you and
take advantage of the Benefits Calculator that was e-mailed to you, you’ll see that you
can in fact save money versus having an increase in your costs.
The Children’s Specialized
Hospital open enrollment period will run from November 9 through November
19. If you have any questions about your benefits, please call Victor Vena
at x5497 or Dana Pettiford at x5560.
Amy B. Mansue
President & CEO
|
Warren Moore
Executive Vice
President & COO
|
