CLINTON HEALTH PLAN : Coverage for Everyone

President Clinton has sent his health refrom bill to Congress. No one can predict the final shape health reform will take. But here is a consumer’s guide to what the new system may be like in California if Clinton’s plan becomes law.

Step One: Picking a Plan

All Americans will receive a standard package of benefits to be delivered by a local network of doctors and hospitals. Local networks can offer additional benefits beyond the basic package, but these will cost extra. you select a network once a year and must receive all your care from the plan. To keep your current doctor, you would select the plan to which he or she belongs. Doctors will be allowed to sign up under more than one plan.

The Basic Benefits Offered to Everyone

Hospital services

Doctors and other health professionals’ services

Emergency services

Prenatal care and well-child checkups

Preventive care such as physicals and mammograms

Mental health care and substance abuse care

Family planning and pregnancy-related services

Hospice care

Home health care

Outpatient prescription drugs

Outpatient laboratory and diagnostic charges

Medical equipment, prosthetic and orthotic devices

Vision and hearing care

Dental services and children

Emergency dental care for adults

Ambulance services

How You Get the Services

You select a plan once a year, with probably as many as 7 to 10 alternatives in an area such as Southern California. The approved plans in the state might include such providers as:

Kaiser Permanente: A health maintenance organization with its own staff of salaried doctors and its own medical centers.

Blue Cross: A managed care network, made up of doctors and hospitals providing services at a negotiated fee schedule.

Aetna: A network of doctors and hospitals assembled by a large insurance company. Other competitors such as Prudential or Metropolitan Life also would be in the market.

Fee-for-service: Resembles traditional medicine, in which you have a much broader choice of doctors and hospitals but pay more.

Step Two: Going for Treatment

All Americans would receive a health security card to be presented at the doctor’s office or hospital. The card would be used with a simple one-page insurance form, replacing the current paperwork blizzard. The card could be used to receive services from any doctor or hospital within the network plan you have chosen for the year.

Step Three: Paying Up

All workers and employers would be required to contribute toward health insurance premiums, with workers paying about 20% of the cost of an average plan and employers about 80%.

If you choose a more expensive plan, you would be responsible for the added cost. The federal government would subsidize poor families and the unemployed. Subsidies also would be provided for businesses with fewer than 75 low-wage employees.

The typical HMO plan would require a co-payment of $10 for an office visit and $5 for a prescription drug.

A fee-for-service plan, with a much broader choice of doctors, would call for an annual deductible of $200 for an individual and $400 for a family. There would be a 20% co-payment for office visits. Drugs would have a $250 yearly deductible.

Other Features

Self-employed individuals would pay both the employer and worker’s premiums but would get a full tax deduction.

Workers can pay their share of the premiums by withholding from wages, withholding from sources of non-wage income or by writing a check directly to the local health alliance.

Workers under 18 are included in their parents’ coverage. Students away at college are covered by the health alliance in the school region.

The Plan’s Advantage and Disadvantages

For five typical health care consumers:

Family Description: Family making $50,000 a year with good employer-provided insurance

Gains: Assured coverage, even if job is lost

Losses: Premium deductions may be greater than family now pays as its share of employer’s medical plan

*

Family Description: Family making $20,000 without insurance

Gains: Assured coverage

Losses: Some payroll deductions, with partial subsidies likely

*

Family Description: Welfare family currently relying on Medicaid

Gains: Access to more doctors and broader coverage

Losses: None

*

Family Description: Single person without insurance now and who can’t get coverage because of current illness

Gains: Assured coverage despite existing illness

Losses: Some payroll deductions

*

Family Description: Retiree relying on Medicare

Gains: Additional benefits, including some coverage for prescriptions and in-home care

Losses: New restrictions on payments to doctors and hospitals could limit access to care for Medicare beneficiaries

Researched by ROBERT A. ROSENBLATT, SARA FRITZ and EDWIN CHEN / Times Staff Writers