Personal Hc Plan Research Paper
I do not have my own personal HC plan as I am considered a dependent child on my parents’ HC plan. With my parents’ HC plan, I am covered with their HC insurance until my 26th birthday.
2. Identify what kind of insurance you have (i.e. traditional insurance or managed HC plan) and who is the healthcare plan provider?
The health care provider that I have through my parents is called Anthem Blue Cross and Blue Shield. The specific health care plan under Anthem that my parents own is called Blue Cross and Blue Shield Service Benefit Plan and it is provided to employees of the federal government. Within this plan, there are two versions of insurance and my family has the basic version.
According to Blue Cross Blue Shield Association (2017), …show more content…
the Blue Cross and Blue Shield Service Benefit Plan is classified as a fee-for-service health insurance plan and a Preferred Provider Organization (PPO). The basic version of this health insurance plan resembles a managed HC plan because, for my family to receive HC benefits from Anthem, we must use preferred providers, or providers that are covered by Anthem, unless in case of an emergency. However, unlike health maintenance organizations, our HC insurance does not require us to obtain a referral from our primary care physician to see a specialist.
3.
How much do you (or your parents/spouse) pay per month for the plan?
My parents pay $376.12 per month for the basic version of the Blue Cross and Blue Shield Service Benefit Plan, or Anthem Blue Cross and Blue Shield (Blue Cross Blue Shield Association, 2017).
4. What the plan’s deductible?
For the basic version of the Blue Cross and Blue Shield Service Benefit Plan, there is no deductible that my parents must pay before our HC insurance starts paying our medical bills (Blue Cross, 2017).
5. What is your co-pay after the deductible is met (i.e. set amount or percentage)
The co-pay or set amount that my parents must pay for medical services depends on the type of medical service that my family and/or I am seeking. For instance, the set amount that my parents must pay for office visits with our primary care physician is a $30 co-pay each time we go in (Blue Cross, 2017). Other set amounts include $40 for each specialist doctor visits, and $125 for Emergency Room at a preferred hospital per visit.
6. Is it a comprehensive plan (does it pay for eye/dental/prescriptions) or does it require additional cost to have eye/dental/prescription. If it is not comprehensive how much is the additional cost per …show more content…
month?
Our health insurance plan is a comprehensive plan since my parents can pay for eye, dental, and prescriptions, either through set amounts of co-pays or a percentage of the billed amount if we choose a preferred provider. However, the HC plan for Anthem Blue Cross and Blue Shield is not extensive in the coverage for both eye and dental visits, because our plan only covers issues which arise from a “medical” condition (Blue Cross, 2017). For instance, our HC plan does not cover routine eye exams, glasses, dental care, and fillings. As a result of my parents valuing our eye and mouth care, my parents have separate vision and dental plans not associated with Anthem. For insurance covering eye and vision care, my family has a plan through VSP and the plan costs $23.21 per month. My family’s insurance plan for dental is through the Government Employees Health Association (GEHA) and the dental plan costs $66.21 per month. Through each plan, items like contacts, glasses, dental x-rays, and cleanings are covered for each of my five family members, including myself, but are limited. For example, each family member is limited to two routine teeth cleanings per year, and we are each allowed 1 pair of glasses every two years.
Prescriptions are covered under my parents’ Anthem Blue Cross and Blue Shield HC plan. By using a preferred pharmacy, the amount Anthem pays is higher than through a non-preferred pharmacy. Based on the type or level of drug, referred to as Tiers, Anthem determines the set amount or percentage that my parents must pay through co-insurance. For example, for a generic prescription, referred to as Tier 1, my parents must pay a $10 co-pay; but for a non-preferred brand prescription, or Tier 3, my parents must pay 60% of the total bill or a minimum of $65 for that specific prescription.
7. What is the coverage for mental health services?
At a preferred provider, Anthem Blue Cross and Blue Shield will provide coverage for professional services from licensed professional mental health and substance abuse practitioners and my parents would only have to pay a $30 co-pay per visit (Blue Cross, 2017). This co-pay is the same as other medical services such as with a primary care physician. Some services for mental health include, individual psychotherapy, psychological testing, clinic visits, and group psychotherapy.
8. Does the plan cover occupational therapy and are there any restrictions (i.e. so many visits per diagnosis)?
Anthem Blue Cross and Blue Shield covers occupational therapy (OT) in settings such as outpatient treatment centers, and hospice (Blue Cross, 2017).
The typical co-pay for OT that my parents would have to pay per day per facility is $30. My family’s HC plan combines physical, occupational, and speech therapy when determining how often Anthem will pay for therapy services for an insured. For instance, Anthem provides each individual enrollee with only 50 visits for physical, occupational, or speech therapy, or a combination of all three therapies, per calendar year. If an occupational therapist believes that the client is improving or benefit more from interventions, the occupational therapist can try to claim additional visits for their clients. The claim, to Anthem, for additional visits can be a written statement by an occupational therapist who details the medical necessity for continuing the services and the anticipated length of time needed for additional
interventions.
9. Is physical therapy or speech therapy covered? Is it better/worse/the same coverage as occupational therapy?
As mentioned in the previous question, each of my individual family members can receive physical and/or speech therapy in addition to occupational therapy. The coverage for physical and speech therapy is the same as the coverage for occupational therapy with even the co-pay being the same. Each member of my family can receive a maximum of 50 visits a year from a physical, occupational, or speech therapist, or a combination of all three rehabilitations.
10. Is the primary policy holder pleased with the coverage? Is the plan easy to follow, have they ever had difficulty with payment?
My father, the primary policy holder, is pleased with the coverage because most of our physicians are considered preferred providers, which allows my mom and him to pay lower co-pays. Additionally, my father appreciates the quality of the medical facilities such as hospitals and out-patient care facilities that fall under our preferred providers. While there have been some disputes about medical claims Anthem Blue Cross and Blue Shield may have disallowed or only partially covered, my parents have used the “appeal” processes and, overall, have found those disputes to have been resolved satisfactorily. My father finds Anthem an easy plan to follow as there is a surplus of supplemental information that make the entire coverage and payment aspects of the HC plan to be easy to comprehend. Even though my parents can switch insurance providers once a year, they have found Anthem provides the best coverage for the best premium and have not had much difficult with payments.
11. You have just turned 26 or you have just lost your HC plan…what are you going to do?
• Please locate a new plan that you would purchase. Keep in mind you should have a budget and remember that you must pay/purchase rent, car payment, utilities, school loans, groceries. o What plan have you chosen?
The plan that I would choose would be Ambetter From Buckeye Health · Ambetter Balanced Care 10 (2017) + Vision + Adult Dental, which is a health maintenance organization.
o Where did you locate the plan?
After finding what the 10% of occupational therapists make, as I may be starting out with a lower paycheck as an occupational therapist straight out of college, I used the annual income of $53,250 to find and compare health care insurance plans that I qualify for on HealthCare.gov.
o What is the cost?
The monthly premium for Ambetter From Buckeye Health is $214.15. The total premium by the end of the year would be around $2,570 for health insurance coverage. Some co-payments or coinsurances that I would have to pay include: $20 for a primary care physician, $40 for a specialist doctor, and 20% coinsurance after deductible for emergency room care.
o What is the deductible?
The deductible for Ambetter From Buckeye Health is $4,500.
o Does it include eye/dental/prescription?
Yes, this plan unlike many other health care plans that appeared to fit my criteria for health care insurance on HealthCare.gov includes some coverage for eye, dental, and prescription services. With eye services, there is one routine eye exam per year that comes with no charge. In terms of dental services, there is no charge for a routine dental care visit if the cost is at or under $1,000 per year. For prescriptions, I would have to pay a co-pay of $10 per generic drug and $50 per preferred brand drug. o What concessions did you have to make in order to purchase the insurance?
The major concession I had to make to purchase the insurance was taking the risk of not having immediate coverage if I ended up in the emergency room. In order to have some coverage of emergency room costs from Ambetter From Buckeye Health, I would have to wait till my medical costs passed $4,500. I put myself at risk because I realized that I needed at least some coverage for one routine eye exam because of my subpar eye sight and this plan appeared to have a fairly low deductible and monthly premium for all things considered.
2. Identify what kind of insurance you have (i.e. traditional insurance or managed HC plan) and who is the healthcare plan provider?
The health care provider that I have through my parents is called Anthem Blue Cross and Blue Shield. The specific health care plan under Anthem that my parents own is called Blue Cross and Blue Shield Service Benefit Plan and it is provided to employees of the federal government. Within this plan, there are two versions of insurance and my family has the basic version.
According to Blue Cross Blue Shield Association (2017), …show more content…
the Blue Cross and Blue Shield Service Benefit Plan is classified as a fee-for-service health insurance plan and a Preferred Provider Organization (PPO). The basic version of this health insurance plan resembles a managed HC plan because, for my family to receive HC benefits from Anthem, we must use preferred providers, or providers that are covered by Anthem, unless in case of an emergency. However, unlike health maintenance organizations, our HC insurance does not require us to obtain a referral from our primary care physician to see a specialist.
3.
How much do you (or your parents/spouse) pay per month for the plan?
My parents pay $376.12 per month for the basic version of the Blue Cross and Blue Shield Service Benefit Plan, or Anthem Blue Cross and Blue Shield (Blue Cross Blue Shield Association, 2017).
4. What the plan’s deductible?
For the basic version of the Blue Cross and Blue Shield Service Benefit Plan, there is no deductible that my parents must pay before our HC insurance starts paying our medical bills (Blue Cross, 2017).
5. What is your co-pay after the deductible is met (i.e. set amount or percentage)
The co-pay or set amount that my parents must pay for medical services depends on the type of medical service that my family and/or I am seeking. For instance, the set amount that my parents must pay for office visits with our primary care physician is a $30 co-pay each time we go in (Blue Cross, 2017). Other set amounts include $40 for each specialist doctor visits, and $125 for Emergency Room at a preferred hospital per visit.
6. Is it a comprehensive plan (does it pay for eye/dental/prescriptions) or does it require additional cost to have eye/dental/prescription. If it is not comprehensive how much is the additional cost per …show more content…
month?
Our health insurance plan is a comprehensive plan since my parents can pay for eye, dental, and prescriptions, either through set amounts of co-pays or a percentage of the billed amount if we choose a preferred provider. However, the HC plan for Anthem Blue Cross and Blue Shield is not extensive in the coverage for both eye and dental visits, because our plan only covers issues which arise from a “medical” condition (Blue Cross, 2017). For instance, our HC plan does not cover routine eye exams, glasses, dental care, and fillings. As a result of my parents valuing our eye and mouth care, my parents have separate vision and dental plans not associated with Anthem. For insurance covering eye and vision care, my family has a plan through VSP and the plan costs $23.21 per month. My family’s insurance plan for dental is through the Government Employees Health Association (GEHA) and the dental plan costs $66.21 per month. Through each plan, items like contacts, glasses, dental x-rays, and cleanings are covered for each of my five family members, including myself, but are limited. For example, each family member is limited to two routine teeth cleanings per year, and we are each allowed 1 pair of glasses every two years.
Prescriptions are covered under my parents’ Anthem Blue Cross and Blue Shield HC plan. By using a preferred pharmacy, the amount Anthem pays is higher than through a non-preferred pharmacy. Based on the type or level of drug, referred to as Tiers, Anthem determines the set amount or percentage that my parents must pay through co-insurance. For example, for a generic prescription, referred to as Tier 1, my parents must pay a $10 co-pay; but for a non-preferred brand prescription, or Tier 3, my parents must pay 60% of the total bill or a minimum of $65 for that specific prescription.
7. What is the coverage for mental health services?
At a preferred provider, Anthem Blue Cross and Blue Shield will provide coverage for professional services from licensed professional mental health and substance abuse practitioners and my parents would only have to pay a $30 co-pay per visit (Blue Cross, 2017). This co-pay is the same as other medical services such as with a primary care physician. Some services for mental health include, individual psychotherapy, psychological testing, clinic visits, and group psychotherapy.
8. Does the plan cover occupational therapy and are there any restrictions (i.e. so many visits per diagnosis)?
Anthem Blue Cross and Blue Shield covers occupational therapy (OT) in settings such as outpatient treatment centers, and hospice (Blue Cross, 2017).
The typical co-pay for OT that my parents would have to pay per day per facility is $30. My family’s HC plan combines physical, occupational, and speech therapy when determining how often Anthem will pay for therapy services for an insured. For instance, Anthem provides each individual enrollee with only 50 visits for physical, occupational, or speech therapy, or a combination of all three therapies, per calendar year. If an occupational therapist believes that the client is improving or benefit more from interventions, the occupational therapist can try to claim additional visits for their clients. The claim, to Anthem, for additional visits can be a written statement by an occupational therapist who details the medical necessity for continuing the services and the anticipated length of time needed for additional
interventions.
9. Is physical therapy or speech therapy covered? Is it better/worse/the same coverage as occupational therapy?
As mentioned in the previous question, each of my individual family members can receive physical and/or speech therapy in addition to occupational therapy. The coverage for physical and speech therapy is the same as the coverage for occupational therapy with even the co-pay being the same. Each member of my family can receive a maximum of 50 visits a year from a physical, occupational, or speech therapist, or a combination of all three rehabilitations.
10. Is the primary policy holder pleased with the coverage? Is the plan easy to follow, have they ever had difficulty with payment?
My father, the primary policy holder, is pleased with the coverage because most of our physicians are considered preferred providers, which allows my mom and him to pay lower co-pays. Additionally, my father appreciates the quality of the medical facilities such as hospitals and out-patient care facilities that fall under our preferred providers. While there have been some disputes about medical claims Anthem Blue Cross and Blue Shield may have disallowed or only partially covered, my parents have used the “appeal” processes and, overall, have found those disputes to have been resolved satisfactorily. My father finds Anthem an easy plan to follow as there is a surplus of supplemental information that make the entire coverage and payment aspects of the HC plan to be easy to comprehend. Even though my parents can switch insurance providers once a year, they have found Anthem provides the best coverage for the best premium and have not had much difficult with payments.
11. You have just turned 26 or you have just lost your HC plan…what are you going to do?
• Please locate a new plan that you would purchase. Keep in mind you should have a budget and remember that you must pay/purchase rent, car payment, utilities, school loans, groceries. o What plan have you chosen?
The plan that I would choose would be Ambetter From Buckeye Health · Ambetter Balanced Care 10 (2017) + Vision + Adult Dental, which is a health maintenance organization.
o Where did you locate the plan?
After finding what the 10% of occupational therapists make, as I may be starting out with a lower paycheck as an occupational therapist straight out of college, I used the annual income of $53,250 to find and compare health care insurance plans that I qualify for on HealthCare.gov.
o What is the cost?
The monthly premium for Ambetter From Buckeye Health is $214.15. The total premium by the end of the year would be around $2,570 for health insurance coverage. Some co-payments or coinsurances that I would have to pay include: $20 for a primary care physician, $40 for a specialist doctor, and 20% coinsurance after deductible for emergency room care.
o What is the deductible?
The deductible for Ambetter From Buckeye Health is $4,500.
o Does it include eye/dental/prescription?
Yes, this plan unlike many other health care plans that appeared to fit my criteria for health care insurance on HealthCare.gov includes some coverage for eye, dental, and prescription services. With eye services, there is one routine eye exam per year that comes with no charge. In terms of dental services, there is no charge for a routine dental care visit if the cost is at or under $1,000 per year. For prescriptions, I would have to pay a co-pay of $10 per generic drug and $50 per preferred brand drug. o What concessions did you have to make in order to purchase the insurance?
The major concession I had to make to purchase the insurance was taking the risk of not having immediate coverage if I ended up in the emergency room. In order to have some coverage of emergency room costs from Ambetter From Buckeye Health, I would have to wait till my medical costs passed $4,500. I put myself at risk because I realized that I needed at least some coverage for one routine eye exam because of my subpar eye sight and this plan appeared to have a fairly low deductible and monthly premium for all things considered.