HCH--The Benefits Gap

HCH--The Benefits Gap

What causes gaps in your benefits? In a nutshell, health care consumers are the ones who suffer the most from benefit gaps. . . . and health care consumers must accept the lion''s share of the blame. Health care plans must respond to competition. Only the enrollees of health care plans can decide how the health care plans respond.

The single most important factor in maintaining and improving the quality of health care plans is informed enrollees. When benefit plans face increased competition for the same premium dollars, their competitive choices are limited. They can offer cheaper premiums or better and more appropriate and comprehensive health benefits. Health care enrollees must 1) become knowledgeable about benefits and 2) insist that employers choose the most benefit-rich and sensible plans.

If we do not do our part, we will be left with health care plans stripped of their most important features and unable to meet the needs of an increasing number of enrollees.

The response to increased competition we are currently seeing is cheaper premiums. The reasons for that are clear. 1) Few health care plan enrollees understand the meaning of their plan benefits. 2) Health care plans have had the freedom to redefine benefits and to disclose only limited summaries of plan benefits to enrollees. Health care plans are not required to characterize the impact of benefit limitations upon the care purportedly addressed by the benefits offered. As a result, enrollees do not learn of benefit limitations until they need services the health care plan claims are not covered. In most cases, the value of critical is diminished or is never delivered. Enrollees are left to make crucial and pressing decisions. They are less prepared than are the experts and the health care plan claims department.

Employers will usually purchase the cheapest plan available. Controlling costs is a primary function of every successful organization, and cheaper health care plan premiums offer a ready way to pare dollars from expenses with no apparent effect upon products or services. On the other side, health care plans diminish premium costs by identifying and eliminating the most costly services that address the needs of the smallest number of enrollees. Health care plan enrollees cannot expect health care plans to improve benefits or provide protective coverage unless they are forced to by the same market force that caused them to reduce premium costs.