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Selecting the Preferred Provider Organization (PPO) Plan That is Right for You!

Which PPO medical insurance plan should I enroll in?  Before you answer that question, please keep in mind that regardless of your selection: 

  1. Both plans are administered by the Capital District Physician’s Health Plan (CDPHP)
  2. Both plans use the Magna Care/First Health network, and
  3. Union will continue to self-insure the plans and therefore be ultimately responsible for claims and cost fluctuations.

PPO Plan  Magna Care/First Health Network

The Preferred Provider Organization (PPO), for our medical insurance plans, provide members with the freedom to see CDPHN physicians without a referral and to see non-participating physicians if they so choose.  The PPO network includes over 725,000 providers, extends coverage to virtually anywhere in the nation--all 50 states plus Puerto Rico, and provides coverage worldwide for emergency care.  For helpful information regarding using the PPO plan and for finding a doctor within CDPHP’s MagnaCare/First Health network, please go to the helpful links under Medical Insurance on the HR Benefits webpage or contact HR directly for a hardcopy of the information.  As with most medical decisions, before receiving treatment, it is generally a good practice to consult the Summary Plan Description (SPD), Summary of Benefit Coverage (SBC), and/or contact CDPHP.

What is the Main Differences Between the Two Plans?

Before the differences are considered, please note that both plans offer in and out-of-network options, require copays for things like physician and specialist visits, emergency room or urgent care visits and prescription drugs, and involve a deductible and coinsurance.  Both plans also offer a limit on financial out-of-pocket exposure.

The PPO Plan U (Higher Premium/Lower Out-of-Pocket) plan, considered a Platinum level plan on the medical exchanges, offers comprehensive coverage with limited financial out-of-pocket exposure, especially when using the in-network option.  Since the in-network option does not have an in-network deductible, financial out-of-pocket exposure is primarily limited to the stated copays.  Financial out-of-pocket exposure is further limited, under the in-network option, by individual and family out-of-pocket maximums for inpatient care and outpatient ambulatory surgery. 

The PPO Plan U out-of-network option has a bit more financial out-of-pocket exposure, with the inclusion of deductibles and co-insurance. The PPO Plan U has lower individual and family cumulative out-of-pocket maximums.  Because of the comprehensiveness of coverage and limited financial out-of-pocket exposure, the premiums for this plan are higher.

The PPO Plan C (Lower Premium/Higher Out-of-Pocket) plan, considered a Gold level plan on the medical exchanges, was developed to offer comprehensive coverage, to promote greater financial awareness in healthcare choices, and to provide lower payroll contributions.  The PPO Plan C offers the potential for savings but also the potential for increased financial out-of-pocket exposure.  The PPO Plan C has both an in-network and an out-of-network deductible.  Depending on how the plan is used, the respective deductible must be met before services subject to coinsurance will be paid.  Where a copay is indicated, the copay is the financial out-of-pocket exposure; where coinsurance is indicated the deductible must first be met before the plan shares in the cost.  

This PPO Plan C has considerably more services covered on a coinsurance basis.  The risk of financial out-of-pocket exposure is therefore increased, up to the stated out-of-pocket maximum amounts.  It should be noted that this plan, unlike the PPO U (Higher Premium/Lower Out-of-Pocket) plan, does not have separate out-of-pocket maximums for in-network inpatient care and outpatient surgery.  Although this plan is also comprehensive, because of the higher deductibles, prevalence of coinsurance, and higher out-of-pocket limits, the premiums for this plan are lower.

So How Do I Decide Which Plan is Right for Me?

Should I select the PPO Plan U (Higher Premium/Lower Out-of-Pocket) or should I go with the PPO Plan C (Lower Premium/Higher Out-of-Pocket)?

You are encouraged to review the plan options, related premiums, and potential out-of-pocket costs, to make sure that you are selecting the plan that is right for you. To make an even more informed decision,  you are encouraged to take a closer look at your past and expected use of medical care services and your financial situation.  You should look at things such as: how many physician’s or specialist visits you normally have, the likelihood that you will require inpatient or out-patient treatment, how many and what kind of prescriptions you normally have, etc.  You are also highly encouraged to take a close look at your financial situation.   Ask yourself whether you are able and willing to handle the financial cost, up to the out-of-pocket maximum, for the plan you are interested in enrolling in?  Ultimately, you will need to make a risk/reward determination.  Do you want to pay higher premiums in return for less out-of-pocket exposure, or do you want to pay lower premiums with more out-of-pocket exposure?  In other words, you are trying to determine if your utilization of medical services will be low enough that your out-of-pocket expenses do not outweigh your premium savings.

A key factor in making your decision is whether you have the financial resources to handle the potential out-of-pocket expenses of the “Lower Premium/Higher Out-of-Pocket” plan.  If you, or a covered family member, require inpatient care, outpatient surgery or any of the other items covered by coinsurance, will you be able to pay the resulting deductible and coinsurance?  This is a personal decision and not one that should be made without due consideration.  Regardless of the plan selected, employees facing financial difficulties should note that programs are available to help deal with short-term monetary issues.  Human Resources can provide you with information regarding loans against your retirement plan or loans available through the Schenectady Area Employer Resource Network (of which Union is a founding member).

To assist you in your decision making, a PPO Plan Selection Tool is available on the HR website.. The PPO Plan Selection Tool uses cost estimates for things like inpatient stays, outpatient surgeries, and durable medical equipment.   Because the PPO Plan Selection Tool uses estimates, your actual experience may vary.   The Tool is available from Human Resources and on the HR website in the Benefits section.   Human Resources is also available to help you with the tool and any other questions you might have.

Hopefully this handout has provided you with some useful suggestions for selecting which PPO plan is right for you.  If you have any questions please contact Human Resources at ext. 6108.