City changes health insurance to self-funded plan
ASK THE MAYOR
MAYOR PHILLIP SPENRATH

Last week your City Council approved a self-funded mode of insurance for our city employees. Self-funded insurance differs from fully-funded insurance because all employee premium payments are placed into a city controlled financial pool rather than being completely relinquished to an independent insurance provider. Hopefully, at the end of the fiscal year, the city will experience a savings provided some of the pool funds go unused.

After much research and discussion, the majority of your City Council supported a self-funded insurance plan believing that it provided our employees with 1) solid health care coverage and 2) a payment system that could potentially save local taxpayers over $100,000 in unused premiums.

In recent days, a number of city employees and local residents contacted your Council members with questions and concerns related to the city's new self-funded insurance plan. While many concerns involved issues and observations related to our city's first go-round with self-funded insurance, the majority of recent inquiries pin-pointed employee out-of-pocket expenses, the scope of benefits, and the opportunity to stay with the physician of one's choice.

As I entered into each conversation, I made it clear that I would continue to give 100 percent of my support to any and all decisions approved by the majority of our City Council, regardless of my own personal viewpoint. Thus, I feel it is important to move forward and try to address some of the concerns and dispel possible confusion generated by our recent insurance decision.

One of the most shared concerns involved employees who wanted to continue receiving medical treatment from their preferred out of town physician. Many of these employees were under the assumption that our recently adopted Entrust guidelines and deductibles were only applicable at our local El Campo Memorial Hospital. As a result, the most frequently asked employee question became how much more will I pay if I choose to seek medical treatment in Houston or some other city?

The answer is exactly the same rate you would have paid under the existing fully-funded plan. Our city's newly adopted Entrust policy is designed to provide our employees with reliable health coverage and our taxpayers with economic efficiency. In an attempt to better explain the coverage provided by our new self-funded plan, it might be helpful to compare Entrust's deductibles and co-pays to those recently submitted by United Healthcare, our city's current fullyfunded insurance provider.

Currently, the city's Entrust Plan and United Healthcare both offer a $20 primary care co-pay and a $20 specialist co-pay. Both plans also have $500 individual and a $1,000 family calendar year deductible.

Concerning emergency room visits, both plans require the employee to pay a $100 co-pay. Finally, the significant difference involves "non-clinic" hospital related visits. Under the fully-funded United Healthcare plan, once the employee's deductible has been met, United Healthcare will pay 80 percent of all remaining expenses while the employee incurs the residual 20 percent.

Under the Entrust self-funded plan, regardless if the deductible is met, the employee must first pay a $250 co-pay for each "non-clinic and non-emergency room" hospital visit. Once the deductible is met, the employees will still pay a $250 co-pay per visit, but will only be responsible for 20 percent of the remaining medical costs. We are told the $250 co-pay was implemented to discourage excessive and unwarranted hospital visits that could potentially drive up insurance premiums.

In comparing the aforementioned figures, our newly adopted self-funded insurance appears to be quite comparable to the fully-funded plan submitted by United Healthcare. While this article does not attempt to address concerns related to stop-loss "cap" insurance and pool funding, it is hoped that the content does provide needed answers and thereby eases some of the uncertainty related to individual out-of-pocket contributions.

Concerning out of town physicians, your City Council was assured that 95 percent of all area and regional physicians were included in the current Entrust plan. Employees can check the status of their health care professionals by going online to www.texastruechoice. com/providersearch.asp.

In today's world of soaring gas, grocery and insurance prices, we must continue to ask the tough questions, be efficient in our planning, and remain creative when seeking new solutions to old problems.

One of my primary goals has and will continue to be providing every citizen with credible information along with open access to your city government.

- Contact the mayor at askthemayor@sbcglobal.net.