UpDate - Vol. 11, No. 29, Page U.D. BENEFITS-4
April 30, 1992
UD Benefits 1992-93
What's right for you?; Traditional BCBS, HMO, Total Health Plus,
   Principal Health

     The University of Delaware offers eligible employees three
traditional Blue Cross/Blue Shield plans and three managed care
programs. Although both approaches provide health care coverage, there
are differences not only in cost, but also in covered expenses,
methods and amounts of payment for services. Also the traditional
approach provides only financial coverage while the managed care plans
provide health care services as well as the payment for services.
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     Traditional Approach
     BCBS Basic, Basic Plus, Comprehensive
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     The traditional approach is primarily concerned with financing
your health care; in other words, these plans provide payment or
reimbursement for the cost of your medical services while a member of
the program. Since this approach does not offer services, you may use
any physician or hospital.
     The three traditional plans are: Basic, Basic Plus and
Comprehensive. While each plan may cover many of the same services,
the payments differ thus resulting in differences in the out-of-pocket
expenses members are required to pay. The three plans each pay 100
percent of the usual and customary cost for the first 120 days of
hospitalization. However, the basic and basic plus plans generally pay
80 percent of usual and customary fees for surgery and anesthesiology;
and the comprehensive plan pays 100 percent of usual and customary
fees for the same services. Also, the basic plan does not cover
out-patient diagnostic expenses. Both the basic plus and comprehensive
plans have annual deductible provisions which differ in the amount of
payments and the covered services. While the basic plus plan
deductible is $100/person or $200/family after which coverage is 80
percent for most out-patient services, the comprehensive plan
deductible is $200/person or $500/family and is applicable only to
prescriptions, doctors' office visits, psychiatric services and
durable medical equipment.
     In order to receive full payment according to the terms of the
contract, it is necessary to follow all Intracorp utilization and
review procedures. (See related insert on this page.)
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     Managed Care Approach
     HMO (Copay), Total Health Plus and Principal Health Care
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     Managed care providers offer their services on a pre-paid basis.
This means that almost all of a member's health care, no matter how
much care is required, is paid for in advance through the premiums
which are paid by the University and the employee. Generally, the only
additional cost may be a small copayment for certain services, such as
doctor's visits, prescriptions, eye exams, etc. Members can
effectively budget health care expenses since payments are fixed in
advance. No record-keeping is necessary since there are no claim forms
to complete.
     These plans emphasize preventive medicine. By encouraging members
to seek out-patient care on a regular basis and when symptoms are
first noticed, the strategy is to treat medical problems early, before
they become serious and the cost of treatment bcomes excessive.
However, this approach requires members to receive health care from
the doctors, hospitals and other health care providers associated with
the specific plan, except in an emergency. Even then, the member is
required to contact the Plan within 48 hours and provide information
regarding treatment. Otherwise, payment may be denied.
     The University offers group practice and individual practice
plans. Our group practice plan, HMO (Copay), provides its members with
all services at its medical facility where the physicians, lab, exam
rooms, etc. are located. The individual practice plans, Total Health
Plus and Principal Health Care of Delaware, have contracts with
individual physicians who agree to treat participants in addition to
private patients who do not participate in the managed care plans.
Rather than pay the full cost of a visit, the member may pay a small
copayment which can range from $5 to $15.
     Under both types of coverage, members select a primary care
physician from a list of participating physicians provided by the
plans. The primary care physician is the person the member sees for
routine physicals and when problems first arise. The primary care
physician provides the treatment and, if necessary, refers the patient
to a specialist who is also associated with the group. Employees
considering a managed care program should keep in mind that in order
to see a specialist, a member must receive a referral from the primary
care physician. If the member receives medical care from a physician
who is not associated with the group, or to whom there was no
referral, then the member will be responsible for all costs associated
with treatment by that physician.
     See comparison chart for details of the University health care
plans.