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Making a People Operations Wiki on Coda

Making a People Operations Wiki on Coda

Medical Plans

Which medical plan should I choose?

Lucy Yip

Legally, we are not able to select or advise a plan for you. We did however create this guide to help you choose the best plan to suit you and your family’s need.

Choosing a medical plan can be daunting. Unfamiliar terminology, health care quality, and cost implications. There isn’t a clear winner with medical plans because it depends on your unique situation and risk tolerance in navigating the unpredictable future. Here are a few things to think through to help make your decision for you and your family.

Identify your needs.

Think about what’s important to you. Do you want to keep your costs for medical services as low as possible?

Are you satisfied with being restricted to a specific group of doctors and having your services referred and authorized by a primary care doctor and medical group? Or do you prefer to access specialists directly without authorizations? Do you or a family member want to see specific doctors, and are those doctors available under the health plan you are considering? Are there specific services or treatments you would like covered? Do you or a family member regularly use prescription drugs, and are the drugs you need on the plan formulary or list of preferred drugs?

Look beyond the premium.

Coda covers 100% of the premium for employees and 100% of premiums for dependent medical coverage, and 100% of premiums for dental and vision coverage. This is an amazing benefit Coda offers and helps remove the guesswork of how much premiums will cost you. Premiums aside, think about how the plan you select will work for you: your access to doctors, the range of benefits and what you pay when you use the services.

Out of Pocket costs

Your out-of-pocket costs are the amounts you should expect to pay for services under your plan. In general, with HMOs you pay set copayments and have no deductible, and with PPOs you are subject to annual deductibles and coinsurance amounts for most services. There may be services for which you must pay a coinsurance under an HMO (for example, infertility treatment on some plans). As a result of health care reform legislation, certain preventive care services are provided at no charge. You can review a plan’s schedule of benefits to learn what your share of the cost will be for specific services.

Plans also have annual maximum out-of-pocket amounts, which are often overlooked. A plan’s out-of-pocket maximum protects you from paying an unlimited amount for services. Once you reach the maximum out-of-pocket, the plan pays 100 percent of most medical services for the remainder of the calendar year.

Understand the basics of how plans work.

HMOs (Health Maintenance Organizations) limit covered services to specific doctors and hospitals, and many services, including consultations with specialists, must be authorized in advance by your primary-care doctor, medical group or health plan. With HMOs, you pay set copays for most services. HMOs generally are more restrictive than PPO plans, but they help keep your costs for covered services lower.

A PPO (Preferred Provider Organization) plan allows you to direct your own care and decide where to obtain most services. You are not required to obtain authorization to consult specialists, but the plan should pre-certify some services — surgeries, for example. If you use the plan’s participating providers, you pay less than if you use providers who are not contracted with the plan. Under a PPO, you are subject to annual deductibles and coinsurance for most services.

Think about what happens when you travel, or if your son or daughter is in college.

If you travel or have a family member who lives out of the area, you may want to select a plan that provides services out of the area. HMO plans cover only emergency and urgently needed services when you are outside of your plan’s service area, with the exception of Kaiser’s Visiting Member Benefits. With United Health Care, you will likely have more flexibility to see providers in other States and areas within California. If a person travels for work or splits time in another area, this can be a big deal. Kaiser is an HMO so you need to stay in the network.

Consider coverage for prescription drugs.

Copays and coinsurance for prescription drugs vary among plans. Most plans have formularies or lists of preferred drugs. If your drug is on the plan’s formulary, your copays or coinsurance for the drug are lower than if the drug is a non-formulary medication. Check the plan formulary to see if your drugs are on it to help keep your costs lower.

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