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Consumer Guided Health Insurance Backgrounder
HealthMarkets: The Force Behind Consumer Guided Health Insurance
HealthMarkets helped create the category of Consumer Guided Health Insurance and continues our tradition as a leading innovator. Headquartered in North Richland Hills, Texas, HealthMarkets specializes in the insurance needs of individuals, the self-employed and small businesses nationwide. Our mission is to provide the best value money can buy for working people who need to pay for health coverage on their own. For over 25 years these Americans have been our customers, and we promise to keep finding better ways to hold down costs without sacrificing important benefits.
Our insurance plans bring the power of the consumer marketplace back to health care, where it has been missing for decades. We call this approach Consumer Guided Health Insurance and it lets our customers have more control over their own spending decisions, so they can make informed choices and minimize out-of-pocket costs.
Our Consumer Guided plans:
- Give consumers the information they need to make the best decisions about their health care.
- Stimulate price and quality competition among providers.
While some companies talk about the need for greater transparency in the health care industry, HealthMarkets is already providing it. We are equipping our customers with quality, value and cost information — so that they can make common sense, informed buying decisions about their health care, just the way they do with any other purchase.
- The idea is that once consumers see real value, they will choose real value — and help keep down costs for everyone.
- Quality indicators — including physician education backgrounds, hospital clinical outcomes and consumer feedback — are provided for all physicians and hospitals listed on our Web site, which help consumers make informed decisions about their health care.
Small businesses and the self-employed feel the true brunt of spiraling health care costs. Today, some 45 million Americans have no health insurance whatsoever.
Part of the solution is affordable health insurance. HealthMarkets Consumer Guided plans are a smart buy compared to many traditional plans - with plan technology that helps control costs and maximize benefits.
Better tools make HealthMarkets better.
Our plans use what we call the Maximum Allowable Charge, or "MAC."
- Our indemnity-based plans use what we call the Maximum Allowable Charge (MAC) - which is the amount the plan will pay for any service. MAC enables price transparency by creating the benchmark that we use to compare against providers' rates.
- Our powerful Web site (or a personal claims assistant) shows consumers which doctors and hospitals generally charge less than the MAC, and which usually charge higher than the MAC.*
- MAC eliminates the need for network restrictions - the MAC stays the same regardless of which provider a member seeks care from.
- How do we set the MAC? We set MAC by analyzing our provider costs on a market-by-market level. The MAC is set such that customers will generally have access to nearby providers who will accept their MAC with little or no additional out-of-pocket expenses to the member.
* Providers change their charges from time to time. When charges exceed the MAC, enrollees will be responsible for the difference. To confirm that a provider's charges will be at or below the MAC, enrollees should speak with their provider before receiving services.
Our SMARTFUNDSSM allowances help control costs.
- SMARTFUNDS allowances help consumers use health care services effectively and spend wisely.
- The SMARTFUNDS benefit can lower premiums by as much as 10-15 percent.
- SMARTFUNDS allowances are maximum dollar limits for treatment of specific medical conditions and procedures — called SMARTFUNDS conditions. The SMARTFUNDS allowance limits the amount the plan will cover.
- SMARTFUNDS allowances are smart. They are not "one-size fits all" but rather adjust for added risk due to age, gender, geographic location, complications and other factors.
- SMARTFUNDS allowances are determined based on statistical analysis of the claim histories of 25 million Americans.
- SMARTFUNDS conditions are generally non-emergent and include conditions that consumers are generally more likely to know about ahead of time so they may have the opportunity to work with their doctor to plan their treatment. Examples of SMARTFUNDS conditions include knee surgery or an upper respiratory infection.
Some say Consumer Guided plans discourage routine or preventive care. With StartWell® Benefits, customers receive first dollar coverage for many routine and preventive care services.
- On day one of coverage, consumers can get access to a benefit that can be used for routine and preventive care services. It can apply for things like check-ups, mammograms, allergy testing, and lab tests — all with no deductible, coinsurance or co-pay. That's the incentive to use the benefit. Here is the incentive to use it wisely — if there's money left over at the end of the year, it can be rolled over for the following year's benefit.
- Customers can feel more secure knowing that many routine or preventive care costs are covered through an account they can control and manage.
HealthMarkets' Consumer-Guided Health plans for individuals have been introduced and well-received in 13 states and the District of Columbia :
- Alabama
- Arizona
- Florida
- Georgia
- Illinois
- Michigan
- Mississippi
- Missouri
- Pennsylvania
- Rhode Island
- South Carolina
- Texas
- Virginia
Consumer Guided Health Insurance plans for small businesses (2 to 50 employees) have been introduced in 11 states:
- Alabama
- Arkansas
- Arizona
- Georgia
- Illinois
- Michigan
- Missouri
- Nevada
- Ohio
- Tennessee
- Texas
