Five Critical Criteria used to compare California carriers.
1. Health Plan pricing in the market. Ultimately, benefits need to be priced well relative to other similar plans on the market. Also, the plans have to make sense financially in today’s world of ever-increasing cost. Some large multi-line carriers like Principle offer extremely rich benefits that have completely priced themselves out of the market. There’s a “sweet spot” where plan design meets the consumer’s budget and that has to be a given when choosing a plan. Interestingly enough, this pricing value is driven by a carriers ability to do well in the following other areas so let’s take a look at them. More information on the major carriers in the California market.
2. Extensive provider network for HMO and PPO. A carrier needs to have as many doctors and hospital in all major areas participate in their HMO and PPO networks. The more the better. This is especially true for PPO plans which is the direction the market is ultimately heading as costs escalate. This is primarily a function of how many subscribers the carrier can bring to the bargaining table with medical and hospital groups. If a carrier covers a significant number of people in a given area, the doctors and hospitals of that area need to contract with the carrier. Also, the carrier can negotiate rates better which is essentially the foundation for PPO plans. PPO’s are big group discounts essentially. Here, bigger is better. You can find more information on how the California health networks work.
3. Flexibility and Scope of plan design. The carrier must also offer a full range of plan options: both rich and value HMO options; a full range of PPO plans from rich copay plans to hybrid lower priced plans; Health Savings Account or HSA compatible plans and strictly catastrophic lower-priced plans. No one’s needs are the same. The carrier should be able to provide for both sides of the spectrum. A key direction in the market today is towards the segmentation of maternity and non-maternity benefit plans on the Individual/Family market. This is a critical consideration or any enrollee who may need maternity coverage in the future. Health Net currently only has one plan with maternity benefits in their PPO portfolio. On the group side, it has been more a move towards higher deductibles and in some instances, generic drug coverage only. The Generic only benefit is more and more prevalent on the Individual/Family side. We feel strongly at http://CalHealth.netthat Brand name prescription is important as more exotic medical conditions can require new drugs that run 10’s of thousands of dollars.
4. Ease of Use. One more time… EASE OF USE. The carrier has to be easy to deal with. This is critical for the day-to-day management of your policy (which we help with) and more importantly, the claims-processing side. Technology is increasingly figuring here. Which carriers have made the investment in the Information systems to facilitate both the membership and claims side. We deal with all the carriers day-in and day-out… common sense and practicality are essential in the carrier you choose.
5. Pricing Stability. Over the past decade, California health insurance costs have increased significantly. Barring major changes, it will likely continue as Americans use more and more health care. The ability to mitigate this increase is primarily a function of a carrier’s management of the above four items. Are they designing and pricing correctly for the market to encourage future rate stability? Can they negotiate well with the medical groups and large hospital chains in the California health market? Do they offer options for carriers to reduce benefits (and cost) and still feel well protected? Have they invested in making their business effective from and IT perspective? These are all important questions that directly your future rates and results as a function of the health carrier’s management.
California health insurance Carrier by Carrier listing in descending order based on our experience
Blue Cross of California
Blue Cross is owned by Wellpoint, which is probably the dominant carrier nationwide in terms of stability and progressive plan design. They are known as Anthem Blue Cross Blue Shield or Unicare in most other States. They have been the ones to beat in the California health market.
1. Plan Pricing – they are consistently priced in the top 1-2 for comparable plans.
2. Network – For PPO plans, they probably the most extensive network with providers in all counties. Over 70K providers and 400 hospitals State-wide plus access to the Blue Card network for family members or employees in other States.
3. Flexibility – On the Small Group side, they started the Employee Elect program which is still the most flexible and easiest to use. They even apply choice to the dental plans as well. They have 4 HMO plans, 5 HSA plans, and 12 PPO plans plus a suite called BeneFit for low cost plans. On the individual side, they consistently bring out new plans from the Right Plan 40 no-deductible PPO plan to the new Tonik health plan suite that the other carriers invariably try to copy 6-12 months later.
4. Ease of Use – They are easiest carrier to do business with. They tend to be the most flexible when dealing with issues and the issues tend to be less frequent than with other carriers. They are ahead of the curve (and have been) with technology both in terms of their internal processes and interaction with groups. New online control panels allow employee additions, terminations, changes and more on the Group side. They can be strict in underwriting (company requirements) and benefit management is definitely there but both of these attributes work ultimately to keep cost down which is the biggest issue (hence #1) in the market now. They the first to unveil an online application and online account management and visibility. Tonik enrollment is completely handled online.
5. Pricing Stability – Their increases as a percentage tend to be in the lower quadrant of the market…primarily due to their work on the above four items.
Blue Shield of California
Blue Shield of California a strong carrier in California and also participates in the Blue Card network for out-of-State employees and family members. It is one of the few non-profits. Cross and Shield are two separate, completely independent carriers at the Small Group (2-50 employees) and Individual/Family level. If PPO is your preferred option, they are a good comparison for Cross and Health Net.
1. Plan Pricing – they are consistently priced in the top 1-3 for comparable plans.
2. Network – For PPO plans, they probably rival Blue Cross with providers in all counties. They probably do not negotiate as well as Blue Cross but may have a better reception from doctors/hospitals because of it. This also affects their pricing going forward. They do allow access to the Blue Card network for employees or dependents in other States. Their HMO is comparable to Cross but neither is thought to be the strongest carrier for HMO plans.
3. Flexibility – They allow selections from the different classes of plans (HMO, PPO, and HSA). They have a full range of plans with one of the last no-deductible PPO Small Group plans on the market. They have 7 HMO plans, 4 HSA plans, and 13 PPO plans on the Small Group side and an equivalent suite of plans on the individual side.
4. Ease of Use – Their Group underwriting is slightly more flexible than Cross but their claims and membership side is not as advanced…especially in terms of technology. Our sources say that they are undertaking a pretty significant IT project to integrate their systems and have been working to bring Small Group resources to the web (behind Cross). On the individual side, they have an online application and online tracking but their underwiting tends to be more involved.
5. Pricing Stability – Their increases as a percentage tend to be in the lower to mid quadrant of the market depending on the class of plan (HSA versus PPO for example). They will need to continue modernizing in order to keep this trend going forward.
Health Net of California
Health Net of California was originally Blue Cross’ HMO many years ago. Traditionally, they were a strong HMO carrier but they have aggressively moved into the PPO market as the future of HMO’s and its cost structure dimmed. They tend to copy Cross’ moves in the market so at least they are smart enough to the follow the leader. If a company’s main focus is HMO and they do not have employees out of State, Health Net is definitely to be considered. On the individual/family side, they are a solid carrier but need more of a PPO track record.
1. Plan Pricing – Health Net tends to copy Cross’ offerings and then under-price the market. In the short-term, this is fine for your company. Long term, the rates always increase and/or change. The only issue is if the increase occurs mid-year and employees have already met deductibles/max-out-of-pockets…making a carrier change difficult. This is true on the Individual/Family side and Small Group.
2. Network – Health Net has a strong HMO network as that has been their bread and butter long before the PPO came along for them. The PPO network should be well represented throughout the State although it’s range probably does not match Cross or Shields, whose experience in the PPO market goes back decades.
3. Flexibility – Health Net copied Cross beneficially in that they copied the nature of Employee Elect where you can offer multiple plans to their employees. They have a full range of plans with 16 HMO’s, 4 HSA’s, and 8 PPO’s. You can see their HMO background from the plan options. On the individual side, they only have one maternity PPO plan but offer a wider range of HMO plans. Their HSA’s are comparable but probably under-priced.
4. Ease of Use – Health Net tends to be pretty reasonable both in terms of enrollment (underwriting) and membership. They are behind Cross and Shield in terms of online capabilities and systems. On the individual side, they tend to be more strict with underwriting and if an applicant’s health is not clean, they have declined a high percentage of apps. Cross and Shield appear to be more pragmatic in terms of actually looking at a person’s health history and making a decision.
5. Pricing Stability – Pricing stability has been a weaker area for Health Net especially on the PPO front. For HMO, they have a good grasp of the market and the model. PPO has been a bit more elusive with more requent and significant changes with their plans. This is to be expected as PPO requires a good 5-7 years of claims experience to truly wrap your head around the model actuarially speaking.
We have listed Blue Cross of California, Blue Shield of California, and Health Net of California separately as they really are the strongest California health insurance carriers that offer both PPO and HMO options. Kaiser is a major carrier but primarily acts as an HMO. There are many other options on the market, but from our experience, they usually are not advisable against one of the above mentioned four.