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Discount Plans in the California Health Insurance Market
Over the last 10 years, as California health insurance costs have increased significantly, there has been an explosion in both the availability and marketing of so-called discount health plans as we term them in the industry. It's important to understand how they work and more importantly, how they do NOT work.
First a quick refresher on the whole point of health insurance protection to begin with. Health insurance is coming full circle back to its original design and intent. Originally, health insurance was structured to actually protect from the really big bill. Typically, you had a choice of high deductible and a very simple plan design. As the market matured, copays, co-insurance, and other bells and whistles began to appear. This trend started in the group health insurance market. Group health plans became a tool to for attracting and keeping valued employees. This benefits "arms race" came with a price tag. In the early 90's, medical claims and the resulting premium increase exploded on to the scene. In response, plan designs retreated towards their original form with higher deductibles.
The advent of Discount health plans
Around this time, advertisements began to appear for plans that were significantly lower - even $10 monthly. What were these plans and more importantly, how were the companies able to offer them for such a low monthly premium. These were the "discount plans".
Essentially, a discount plan allows the member to take advantage of negotiated rates across a network. This is the same discount afforded to PPO members when they use a PPO provider. The discount plans can reduce the cost of the medical care by a certain percentage (usually 30-60%) but they lack the one crucial feature of a California comprehensive health insurance plan...the maximum out-of-pocket. This max out of pocket is the real reason to have health insurance or any type of insurance for that matter. The whole part of insurance is to cap your exposure in a given situation of catastrophic health issues. The problem with discount plans is that they typically do not have a cap on the back-end. This means that with a $100,000 health claim, you may have it discounted by 40% but you're still responsible for $60,000. The underlying health insurance costs have skyrocketed and it's possible to have claims of 100's of thousands of dollars...especially for facility based care (hospital, surgicenter, etc).
A good way to tell if a prospective plan is a "discount plan" is the pricing. If it seems to good to be true, it probably is. They other big determining factor is if they advertise that they that you cannot be declined due to health. For individuals and family health insurance plans in California, people are required to go through medical underwriting, which means that they must qualify based on health. This doesn't apply to Group health insurance plans which are guaranteed issue. If the ad says that you will not be declined, that is a clear signal that there is an issue. In health insurance, there is something called "Adverse Selection". This means that a plan which attracts higher risk members will eventually collapse under the weight of its claims issues. The only way a discount plan can avoid this "adverse selection" is to not really pay claims. They are offering discounts...not payments to claims.
Alternatives to discount plans
It's important to make sure you cover the big bills. To keep costs down, we recommend quoting the lowest cost, comprehensive plans on the market. This typically falls under the HSA (Health Savings Accounts) or high deductible plans. The nice thing about the HSA plans is that they are comprehensive...they don't carve out benefits as some of the hospital plans on the markets do. You can run your own individual/family health plan instant quote on HSA and other health plans.
Dennis Jarvis is a licensed California broker with extensive knowledge of the Individual and Small Group health market in California. California health insurance
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