Princeton Weekly Bulletin October 19, 1998
What are your health care options?
With the elimination of the Princeton Health Care Plan on January 1, the University will alter the array of health insurance it provides to employees.
During the open enrollment period from October 19 to November 13, employees previously enrolled in the indemnity plan will need to elect a new form of health coverage, ranging from a new Preferred Provider Organization (PPO) plan administered by United HealthCare to one of three health maintenance organizations (HMOs). A chart on page 7 gives details on each plan, including rates.
PPO
The PPO plan administered by United HealthCare comprises a network of credentialed service providers who commit to discounted rates. An individual can receive care from within the network, or go outside the network at a higher cost. When the individual chooses to receive care within the network, there is no paperwork. The individual makes a $10 copayment for office visits and pays 10 percent of other expenses, such as inpatient hospital care, after a deductible has been met ($300 for an individual, $600 for a family).
When the individual receives service outside the network, the PPO plan functions more like an indemnity plan: The individual pays for services out of pocket and submits paperwork for reimbursement of 80 percent of the outlay, after the deductible ($600 individual, $1,200 family). Some routine care received in the physician's office is covered at an 80 percent reimbursement rate when received out-of-network.
Annual expenses through both in-network and out-of-network options are capped by a coinsurance limit keyed to the individual's salary.
If they do nothing, employees who currently maintain coverage in the Princeton Health Care Plan's Premium Plan option or anything more than Employee Only coverage in the Standard Plan will default into the new PPO with the same type of coverage.
POS
Subscribers to the Point of Service (POS) plan administered by Oxford Health Plans have the same option to avail themselves of discounted services in-network, or to go outside the network at higher cost. Unlike the PPO, the POS requires subscribers to obtain a referral from the primary care physician to obtain specialized services within the network.
The individual makes a $10 copayment for in-network office visits. As with the PPO, the individual pays 10 percent coinsurance for in-network hospital services, though there is no deductible, and the coinsurance limit is a flat $2,500 per person or $5,000 per family. The POS reimburses 70 percent of expenses for out-of-network doctor visits for medical treatment or maternity after a deductible ($1,500 individual, $3,000 family). However, some physicians' services are not covered at all when received out-of-network. Out-of-network hospital care is covered at 70 percent after the deductible. The coinsurance limit for out-of-network care is $7,500 per person and $15,000 per family.
HMOs
Princeton offers four HMOs. Aetna U.S. Healthcare HMO-NJ/PA offer services in a participating physician's office. HIP Health Plan of New Jersey and HMO Blue offer services either in an individual physician's office or in a health care center.
All four offer 100 percent coverage, with small copayments, for the full range of physicians' services and for hospital services. There are no deductibles. The primary care physician is responsible for the patient's care and refers him or her to specialists who participate in the plan. Services not authorized by a participating physician are not covered.
Prescriptions, precertifications
Princeton employees enrolled in any of the University health care plans receive coverage for prescriptions. The four HMOs and the POS provide their own prescription plans. The PPO uses Merck-Medco Managed Care Inc. (PAID Prescriptions), the same prescription plan used by the Princeton Health Care Plan.
All the University health care plans require precertification of emergency room visits and inpatient hospital stays. Failure to precertify in accordance with the terms of the individual plan risks a penalty or nonpayment.
Catastrophic Care Plan
If they do not select any coverage during the open enrollment period, employees who currently maintain Employee Only coverage in the Princeton Health Care Plan's Standard Plan option (the only form of coverage for which the University currently assesses no monthly premium) will default into a new catastrophic health care plan, which will have no monthly premium but will offer indemnity coverage only after a $4,000 deductible.