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State’s small businesses get health-insurance plan

01:00 AM EDT on Friday, August 24, 2007

By Elizabeth Gudrais

Journal State House Bureau

PROVIDENCE — Business owners and insurance brokers heard, for the first time yesterday, the details of a new health-insurance plan that aims to bring down the cost of care for small businesses and their employees.

The plans will be available soon. Blue Cross and Blue Shield of Rhode Island and UnitedHealthcare of New England will each offer a version of the so-called HealthPact plan, with coverage available to all Rhode Island companies with 50 or fewer employees beginning Oct. 1, with a mid-September deadline for getting employees signed up.

United’s will cost an average of $310 a month for individual coverage; Blue Cross’ will cost an average of $321 a month.

That’s a significant savings from the cost of a typical employer-sponsored plan — approaching $500 a month for an individual. But what’s really remarkable about the new plans is that they will help to bring down the overall cost of health care by encouraging healthy and cost-conscious behavior, instead of just shifting the cost of care to the consumer, said Matthew Stark, policy chief in the office of the state health insurance commissioner.

That means consumers will have to cooperate to qualify for the low-cost plans. “Employees have to understand that they’re going to have new responsibilities required to get these rewards,” Stark said.

Among those responsibilities are designating a primary-care physician upon enrollment. The Blue Cross plan requires a referral to visit a specialist, rather than that primary-care doctor; the United plan does not require such referrals.

Both plans require subscribers to fill out a “health risk assessment” upon enrollment, and to have a primary-care doctor fill out a similar assessment within six months.

At least initially, the plans will focus on two areas: tobacco use and obesity. Someone who does not smoke and has a body-mass index within the range considered healthy will sign a pledge to maintain a healthy weight. Smokers will be asked to quit or at least participate in a smoking-cessation program. People whose primary-care doctors designate their body-mass index as unhealthy will be asked to participate in a “weight-management program.”

The plans also require subscribers to participate in “disease-management programs” for chronic diseases such as asthma and diabetes, if a primary-care doctor recommends it.

Subscribers who do not comply with these requirements will be bumped from the “advantage” plan into what the insurers are calling the “basic” plan. The premiums will stay the same — so employers will not have to pay more based on employees’ failure to comply — but subscribers will see higher deductibles, copays and out-of-pocket expenses.

For instance, in the Blue Cross version, an individual would see the deductible increase from $750 to $5,000. The lifetime benefit maximum for the “basic” plan is $1 million; the “advantage” plan has no cap. The copay for a visit to a primary-care doctor would increase from $10 to $30, and the copay for a visit to a specialist from $50 to $60. Copays for prescription drugs would also increase.

Both versions carry a $100 copay for urgent care, and a $200 copay for an emergency-room visit, but the emergency room copay is waived if the person is admitted to the hospital.

Representatives for the insurers noted yesterday that if one family member does not comply with the plan rules, the entire family will be shifted from “advantage” to “basic.” If that shift occurs, the subscriber will not have a chance to get back into the “advantage” plan until the employer’s annual renewal date.

Remaining to be seen is how hard a line the insurers will taken on shifting people out of the more favorable plan. Stark said yesterday that at least at first, they will define some of the criteria relatively broadly. For instance, he said, the insurers are essentially leaving it up to subscribers to determine, along with their doctors, what constitutes an acceptable weight-management plan. It could be anything from a structured program such as Weight Watchers or Shape Up Rhode Island to a self-imposed program of walking the dog each morning, he said.

Also remaining to be seen is how popular the plans will be. Each insurer is capping enrollment at 5,000. They are encouraging people to sign up soon, and will not penalize employers who switch coverage plans prior to their regular annual renewal date, Blue Cross and United representatives said yesterday.

The insurers emphasized that the premiums they quoted yesterday are averages, and that the prices they offer to individual companies will vary based on factors including the average age of each company’s work force. The insurers will use the same small-group rating system they use in other plans they already offer to small businesses, they said.

Yesterday’s information session at the Providence Marriott, which drew about 125 people, was organized by the Cornerstone Group, a West Warwick-based benefits advisory firm that counts among its clients more than 700 small businesses in Rhode Island. The Cornerstone Group will be assisting current clients and new clients with enrolling in the new plans, Amy L. Gallagher, a senior consultant with the firm, said yesterday.

The HealthPact plans grew out of an initiative by Governor Carcieri and the General Assembly during last year’s legislative session. The health insurance commissioner’s office worked with Blue Cross and United to develop the plans in conjunction with representatives of small business and other community members.

egudrais@projo.com

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