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Cost Sharing Questions
FILCO Cost Sharing Plan Evaluation |
The latest trend in managed care in the metropolitan area is the increase in cost sharing products. Cost sharing products were introduced in New Jersey over three years ago and are now being offered by many carriers in New York, specifically, Oxford, United Healthcare, Guardian / Healthnet, Aetna and Horizon.
Each of the carriers have adopted different rules with regard to what is actually covered in the physician’s office by the office visit co-pay. This should be reviewed carefully with your clients.
FILCO has requested each carrier answer four specific questions regarding in network payments to providers. Based on these answers, FILCO has the following comments on the cost sharing plans:
Horizon Healthcare’s 100/90/70 PPO and 100/90 EPO as the most liberal in payment of benefits to its providers. Horizon has had many years of experience in cost share plans, introducing them in New Jersey over 3 years ago. Based on this they have established payments for procedures that other carriers do not pay within the co-pay at this time. In addition the PHCS network is available outside NY and NJ for all Horizon members.
Aetna has created its Managed Choice products that offer flexibility in design to have either a deductible with 100% coinsurance, no deductible with coinsurance or with the MC 10 plan there is NO Deductible and NO Coinsurance in-network . In addition they streamlined what is paid in the physician’s office. The MC product has only a 60% participation requirement after spousal waivers, unless you wish to offer two plans (available for 10 enrollees or more) then participation is 75% after spousal waivers.
United Healthcare has priced their cost share products very competitively and has gone the extra step of keeping x-rays taken and viewed by and in the physician’s office as part of the co-pay.
Oxford Direct plans are very similar to United with the main exception that radiological services are not covered under the co-pay.
Guardian / HN has created in-network cost share plans that only pay for a PCP or OB/GYN under the co-pay. All other services are subject to deductible and co-insurance. These plans seem the least attractive of the cost share plans.
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Please note all questions relate to the in-network portion of the cost sharing plans.
Q1: A patient goes to a dermatologist and has a mole removed in the office. The mole is sent out for a biopsy. What is covered under the co-pay and what is covered under the deductible/coinsurance?
United Healthcare |
Oxford |
Guardian / HN |
Aetna |
Horizon |
All of the procedures done in an office setting would be covered under the co-pay. The biopsy, if done at an outside lab, would be subject to deductible and coinsurance. |
This would be covered by the members Specialist office visit co-pay. |
The office visit and removal of the mole would be covered by the co-pay, the biopsy would be subject to deductible and coinsurance. |
In NY only inpatient hospital services and outpatient surgery are subject to the in-network deductible and coinsurance, so surgery in the dermatologist’s office and the biopsy are covered under the specialist co-pay. |
Covered under the co-pay including the consultation for the examination, diagnosis, and treatment. No additional co-pay required for the biopsy utilizing a participating lab. |
Q2: A patient with a potential broken ankle needs x-rays. How are they covered?
United Healthcare |
Oxford |
Guardian / HN |
Aetna |
Horizon |
If the x-rays are taken and reviewed in the doctor’s physical office they would be covered under the co-pay. If the x-ray facility is in the same building but a separate entity and operating under a different tax identification number or they are done at a separate facility, the cost of the x-ray would fall under the deductible and coinsurance |
If a member goes to the Emergency Room they are subject to deductible and coinsurance, if an Urgent Care center they are subject to the co-pay when in network. If a member goes to the specialist office they have a co-pay for the visit and deductible and coinsurance for the x-rays. |
If the patient goes to his/her PCP or Specialist in the office and the X-ray is taken in the office, then the X-ray is covered under the office visit co-pay. It the X-ray is sent out or is taken at any other place of service (clinic, hospital) then it is subject to deductible and coinsurance. |
In physicians office it is covered with applicable office visit co-pay. In the emergency room the emergency co-pay applies and as inpatient hospital subject to deductible and coinsurance. |
There are three possible scenarios as follows: 1.) If the patient goes to his network physician it is the co-pay. 2.) If the patient utilizes an outpatient facility it is subject to deductible and coinsurance and 3.) If the patient utilizes an emergency room the deductible and coinsurance. |
Q3: A patient goes in for a routine physical with their PCP. What is covered under the office visit co-pay (i.e. blood work, urine analysis, etc.).
United Healthcare |
Oxford |
Guardian / HN |
Aetna |
Horizon |
Basic tests and labs that are done as a part of a routine physical are covered and are not subject to deductible and coinsurance. |
All is covered under a routine exam, including the actual exam by the doctor and their staff. |
All routine procedures that are done in the office that are not listed as an exclusion. |
When done as part of a routine physical exam, all necessary tests, immunizations and reports are covered under the office visit copy. |
Eligible in network charges are paid at 100%. Routine physical includes a complete medical history, diagnostic and screening tests including those necessary because of age, sex and medical background. |
Q4: What services are subject to the In-network deductible/coinsurance – are services categorized by type of procedure, by type of billing, by status of provider, or by provider tax ID#?
United Healthcare |
Oxford |
Guardian / HN |
Aetna |
Horizon |
The level of coverage is determined, not by the type of procedure billed, but based upon the status of the provider (contracted or non-contracted), place of service and the related tax identification number of the provider. |
The services subject to deductible and co-insurance can be determined by type of procedure, status or type of provider and location of service provided. |
The specific services that are subject to co-pay are Physicians Office Visits, Preventive Care Office Visits, Allergy Testing, and Emergency Care at Physician’s Office and Emergency Care at UR Center. All other covered services including, but not limited to PT/OT/Speech, maternity Care, Inpatient Care, Home Health or Hospice are subject to Deductible and Coinsurance. |
The in-network deductible will apply only to: Inpatient Hospital confinements, including inpatient stays for maternity, mental health/substance abuse, skilled nursing facility, hospice, etc.; and Outpatient Surgery. |
Most services provided in a network physicians office are not subject to the in network deductible and coinsurance. These include x-ray, lab, Chiropractic Care, diabetic services and supplies. Services rendered in an outpatient setting by a network physician are subject to the in-network deductible and coinsurance with the exception of x-ray and lab. |
Sample Plans and rates:
United YS-T O/A |
Oxford F-Dir 25/40 |
Guard/HN 400R NYT |
Aetna MC OA-6 |
Horizon EPO 100/90 |
Ded In 1,000 Out 2,000
$25 Co-pay
Co-Ins In 80/20 of $15,000
Co-Ins Out 60/40 of $15,000
Rx Card 7/30/50 – 50ded |
Ded In 1,000 Out 2,000
$25/$40 Co-pay
Co-Ins In 80/20 of $10,000
Co-Ins Out 60/40 of $10,000
Rx Card 10/25/50 – 50ded |
Ded In 500 Out NO Benefit
Co-pay PCP Only $20
Specialist – Ded & Co-ins
Co-Ins In 90/10 of $25,000
Rx Card 15/25/40 |
Ded In 1,000 Out 2,000
$25/$50 Co-pay
Co-Ins In 100%
Co-Ins Out 80/20 of $10,000
Rx Card 10/25/35 |
Ded In 3,000 Out No Benefit
$30/$45 Co-pay
Co-Ins In 90/10 of $10,000
Rx Card 15/25/50 – 100ded |
Manhattan Rates – Second Quarter 2004
Single $265.74
EE/Spouse $536.04
EE/Ch $486.31
Family $797.22 |
Single $271.00
EE/Spouse $596.20
EE/Ch $501.35
Family $840.10 |
Single $282.94
EE/Spouse $622.47
EE/Ch $523.45
Family $848.81 |
Single $257.03
EE/Spouse $547.37
EE/Ch $462.51
Family $752.86 |
Single $223.54
EE/Spouse $447.09
EE/Ch $402.38
Family $693.43 |
Please note that the above cost sharing plans represent an introduction to these plans and are priced on the higher end . Plans are available as low as $150 per single for those clients who may wish to carry a larger share of costs. |
