The prediction of the demise of Health Maintenance Organizations (HMOs) may have been premature. Many people were enrolled in HMOs in the 1990s, but the popularity of HMOs declined as physicians and patients objected to some of the plans' restrictions. However, more and more people are reconsidering HMOs today as these plans keep costs more affordable: participating providers - doctors, hospitals, and other health care providers - manage and coordinate care for their patients. This model encourages information sharing between physicians and prevents unnecessary tests and procedures.

A lot has changed in the health care market since the 1990s. Average family premium costs have skyrocketed from $5,791 in 1999 to $13,375 in 2009, according to a Kaiser Family Foundation study. Employers are paying an average of $5,613 more per employee with family coverage than they did in 1999 - a 132% increase. Consumers are also bearing a larger share of these cost increases with higher premium contributions, deductibles and copays. So what's the solution? Some employers are returning to HMOs and limited network plans.

Limited network plans are expected to play a big role in the health insurance exchanges that will be introduced in 2014 under the federal health reform law. Because physician and hospital costs vary more based on market clout rather than quality of care, the sickness of the population, or the complexity of services ( Attorney General's March 16, 2010 , "Examination of Health Care Cost Trends and Cost Drivers"), limited network options can allow health plans to provide access to high quality providers at lower costs. The recently enacted Massachusetts Small Business Law also provides for limited network plans to help keep costs under control. The New York Times reports (July 17, 2010) that businesses of all sizes will gravitate toward limited plans, reducing premiums by as much as 15 percent by offering these plans.

For GIC members, premium savings for limited network options can exceed these national employer savings. Employees who selected Tufts Health Plan Spirit over the Tufts Navigator option during annual enrollment saved 21% off their premium cost effective July 1. Employees who chose Harvard Pilgrim Primary Choice Plan over the Harvard Pilgrim Independence Plan enjoyed similar savings. All of the GIC's PPO-type plans now offer limited network plans at lower premiums than their larger provider access counterparts. GIC HMOs by definition are limited network plans and offer savings compared to other options, and benefits are essentially the same (with a few exceptions) in all GIC plan types. The major difference between the lower cost plans and the GIC's other plans is the size of the network.

So when does a limited network plan make sense for you?

Your own and your family's health care needs vary over your lifetime and it's important to weigh your options each year at annual enrollment time:

  • Doctors and hospitals move in and out of health plan networks. At annual enrollment, check to see whether your providers are still in your health plan or a health plan you are considering:
    • Be sure you are specific about a particular plan's name when contacting a health plan to find out whether your doctors and hospitals participate in that plan.
    • If you or a family member have a serious medical condition and are currently involved in a treatment program with a particular physician or hospital that you do not wish to interrupt, it's important to confirm whether those doctors and hospitals participate in your current health plan or plans you are considering as of July 1.
  • When you choose a health plan, you must remain in that plan until the next annual enrollment period. The only exceptions to this are if you move out of a plan's service area.
  • Weigh how much more you are willing to pay for wider provider choice.

The following chart provides basic information on the number of providers and relative premium costs by GIC employee health plan.

Provider Access and Plan Cost - July 1, 2010

GIC Employee / Non- Me dicare Plan

# Massachusetts
Physicians

# Massachusetts
Hospitals

Premium
Cost

Fallon Community Health Plan Direct Care

5,000

19

$

Fallon Community Health Plan Select Care

12,700

55

$$

Harvard Pilgrim Independence Plan

24,200

70

$$$

Harvard Pilgrim Primary Choice Plan

17,900

57

$$

Health New England

6,500

15

$

NHP Care (Neighborhood Health Plan)

16,000

63

$$

Tufts Health Plan Navigator

22,400

70

$$$

Tufts Health Plan Spirit

5,800

29

$$

UniCare State Indemnity Plan/Basic

All doctors

All hospitals

$$$$$

UniCare State Indemnity Plan/Community Choice

All doctors

44

$

UniCare State Indemnity Plan/PLUS

All doctors

70

$$$

The bottom line - you don't necessarily need access to every doctor and hospital. What's most important is that you select a plan that includes the doctors and hospitals you and your family are likely to use.


This information provided by the Group Insurance Commission .