PSHB Plan Benefits

I need good psychiatric benefits. What plan is best?

The mental health parity requirement—which theoretically allows unlimited mental health services at the same cost as physical health services—arguably makes all plans meet your needs. But plans require using preferred providers to get network rates. First, talk to your provider and see if he or she is preferred under any plan. If so, this plan is likely to be your best choice. Alternatively, most plans will pay sixty or seventy percent of the plan allowance for out-of-network visits. Since that is well below what most providers charge, you will likely pay half or more of the cost of each visit. Estimate the number of visits you are likely to make and how much each of several plans will pay for these visits. Then add the annual premium cost to the amount that you will pay the doctor under each of those plans. If one of them stands out, you have an answer. If they are all about the same, choose on some other basis (like our overall ratings). Finally, you are a perfect candidate for a Flexible Spending Account, and your FSA tax savings will reduce your cost by about a third.

I am trying to identify the best coverage for mental health services. Is there a good way to identify and compare this type of coverage using the tool?

All PSHB plans now provide a theoretically unlimited mental health coverage at the same cost-sharing as for physical health coverage in network, and most national plans will also cover out of network at a higher cost to you. This applies to both hospital and outpatient care. But two problems remain. First, plans limit the number of preferred providers in their mental health networks, often more stringently than for other coverages, and often by providing better access to clinical psychologists than to expensive "talk therapy" physicians. Second, plans often require pre-approval for coverage beyond a limited number of visits. This is one of those benefit areas where it is best to talk to your provider about which plans will cover his or her services the best. The providers have a great deal of experience with patients in different plans. Assuming that no plan covers the provider you want to use, a lot hinges on things like the number of visits and charges involved. Regardless, you should join one of the plans that promises to cover out of network providers at 60 or 70% of the plan "allowance." This usually means the plan will in practice pay less than half.

Most you could pay in a year? Is this the total out of pocket expense we will incur including the premium and how is this different than Estimated Average Yearly Cost for Families Like Yours?

The "most you can pay" in a year is the plan’s stated annual out-of-pocket limit on the very most you could pay PLUS the plan’s annual premium (and, in a few cases, union dues if these are part of the price of joining). For example, if one plan had a limit of $10,000 and annual premium of $5,000 we would enter $15,000. If another plan had an OOP limit of $5,000 and annual premium of $10,000 we would also enter $15,000. The average for families like your will always be far lower because most people have expenses of just a few hundred dollars year. Note that we adjust premium amount for employees for "premium conversion" tax savings of about a third that employees, but not retirees, all receive.

Is there a best way to determine what different insurance companies consider "usual and customary fees" in a given geographical area? I'm particularly interested in the mental health benefits. It seems that there may be more variability in customary charges than in the standard 30% co-pay. Is the only way just calling each of the health plans?

Health plans do not base reimbursement on "usual and customary" anymore. Instead, they set a "plan allowance" which for a particular procedure might be $100. All network providers must accept that amount. You would pay the plan’s copayment, which might be $30 for this kind of preferred provider visit. If you went out of network to a provider who charged $150 for the same procedure, most national plans would pay a set percentage of the "plan allowance," such as 60%. In this example the plan would pay $60 (60% of $100), and you would pay $90 (the remainder of the $150). Plan allowances generally vary by location, often down to the zip code level. Plans do not disclose the "plan allowance" for your zip code in advance. But there is a solution. You can ask the out-of-network provider his charge, and also ask what that provider’s experience has been with your plan. If you don't get an answer you like, choose another provider.

I'm trying to find the best health plan that has lower costs for diabetic supplies.

We compare plans for diabetic supply coverage in the coverage features section of the Guide. This is a very rough comparison and doesn't capture details. We suggest that you select two or three plans that otherwise look good to you, and then download the brochures for them and search those PDF files for diabetic supplies. There you will see specific details and you can make a side-by-side comparison to see which one(s) cost the least for the supplies that you need. But don't pay a lot of extra premium for a plan that will only save you a few hundred dollars a year on supplies. Also, be sure to set up a Flexible Spending Account for the amounts you estimate you will pay out-of-pocket for these and other costs, to get tax savings that amount to about a one-third discount on what you would otherwise spend.

Is there anyway to determine the coverage for ambulances and emergency airlift after an accident abroad?

This is one of the benefits that we do not analyze in detail. All plans cover medically necessary emergency costs at home or abroad, generally at a cost to you of several hundred dollars. Some specifically cover air ambulances and some do not. There is a section on "emergency services/accidents" in every brochure, so you can narrow your choice to a few plans based on overall costs, and then compare those brochures in detail for emergency details. For travel abroad it often makes sense to purchase a travel policy that covers air ambulance.