Choosing a Good Health Plan

Whether you end up choosing an indemnity plan, PPO, POS, or HMO plan, there are a number of important things to consider in choosing the right one. These include: services offered, choice of providers, location, costs, and quality of care.

Few indemnity and managed care plans cover treatments that are experimental. Ask how the plan decides what is or is not experimental. Find out what you can do if you disagree with a plan's decision on medical care or coverage.

Cost

The following plan features affect how much you pay for your health care:

• Premiums.
  The overall cost of providing the plan is called the premium. In most cases, you pay a portion of the premium through payroll deductions, while your employer contributes a portion on your behalf.
• Deductibles.
  In some plans, you have to meet a deductible. This means that you pay a certain amount of health care expenses each year before the plan begins to pay for your care. Some plans, such as HMOs or POS plans, may not require that you meet a deductible if you use in-network services.
• Copayment/coinsurance.
  You'll usually pay something out-of-pocket each time you see a doctor. In an HMO or POS network, it is probably a set dollar amount (around $10) called a copayment. In an indemnity plan, PPO or non-network POS plan, you typically pay coinsurance . a fixed percentage of the covered charges . and any charges not covered by the plan.
• Out-of-pocket maximum and lifetime maximum.
  Many plans have an out-of-pocket maximum. If you pay enough in medical costs to meet this maximum, the plan will pay 100% of your medical costs for the rest of the year. If you expect high medical expenses, you may want to find a plan with a low out-of-pocket maximum. Some plans also have lifetime maximums which cap how much a plan will pay in your lifetime. Once you reach your lifetime maximum, your plan will no longer pay for your care. Most HMOs do not have lifetime maximums. If you expect to have significant medical expenses, make sure to check the plan's lifetime maximum.
• Exclusions and limitations.
  There are some services that plans won't cover . usually because they are not considered medically necessary. In addition, some services, such as mental health and substance abuse treatment, may be limited. Review each plan's exclusions and limitations. Keep in mind that you have to pay the full cost of care that isn't covered.

Choice

What doctors, hospitals, and other medical providers are part of the plan? Are there enough of the kinds of doctors you want to see? Do you need to choose a primary care doctor? If you want to see a specialist, can you refer yourself, or must your primary care doctor refer you? Do you need approval from the plan before going into the hospital or getting specialty care?

Quality of Care

Quality is hard to measure, but more and more information is becoming available which will enable consumers to quantify quality in a health plan. There are certain things you can look for and questions you can ask. Whatever kind of plan you are considering, you can look into the quality of individual doctors and hospitals.

There are a number of sources of information available that can be used to determine which plan offers the best quality of care. Although relying on any one of the following indicators alone is not enough to determine a plan's overall quality, taking all of these pieces of information into account when selecting a health plan provides a more accurate picture of the plan's ability to provide quality care.

• Check whether the plan is accredited.
  This means that the plan has passed certain quality tests. Look for accreditation by National Committee for Quality Assurance (NCQA) for HMOs and POS plans (www.ncqa.org); American Accreditation HealthCare Commission/URAC for PPOs (www.urac.org); and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) for hospitals (www.jcaho.org).
• Ask your employer for a "report card" that grades the plans.
  If one is not available, you can look for report cards on the NCQA web site or through certain publications, like U.S. News and World Report.
• Ask for your doctor's opinion of the plan.

To research the quality of an HMO or POS plan:

• Ask your employer or health plan for a HEDIS (Health Plan Employer Data and Information Set) report. It can tell you:
  • how satisfied current members are
  • the percentage of members and doctors who have recently left the plan
  • the plan's record on preventive care . for example, in the past year, how many eligible members were immunized, received prenatal care and were screened for cancer
  • the plan's ability to treat chronic conditions (e.g., does the plan have special disease programs for ailments like heart conditions, diabetes and arthritis)

Location

Where will you go for care? Are these places near where you work or live? How does the plan handle care when you are away from home? What if a family member, like a son or daughter in college, lives in a different part of the country?

Ask Yourself:

• Do you have a favorite doctor whom you wish to continue seeing?
  • If so, find out if your doctor belongs to, or is interested in joining, any network plans available to you. The same doctor will cost less when seen through a PPO, HMO or POS network. If your doctor is not in a network plan, you could use both your doctor (at a higher cost) and network doctors (at a lower cost) through a PPO or POS plan. If you don't wish to use network providers at all, an indemnity plan or a managed care plan with good out-of-network coverage may be best for you.
  • If not, a managed care plan, such as an HMO, PPO or POS plan, can provide quality doctors at a lower cost than an indemnity plan.
• Is it important for you to see your own specialists?

  In HMOs and POS networks, your primary care physician has to approve specialty care in advance. More often than not, this approval is easy to get and you'll usually have some choice among network specialists. Note: some primary care doctors only refer patients to specialists in their own practice, and some doctors may not be accepting new patients. This can be misleading if you think you have access to everyone in the plan directory. You may want to call the plans you're considering and ask about their access to specialty care.

• Are certain medical issues important to you?

  Different plans cover different services. Some plans place limits on the amount they will pay for certain services. It's important to find out whether . and how . the medical conditions important to you are covered. To do so, look at each plan's benefit description material or call the health plan. You can also ask your employer for a HEDIS (Health Plan Employer Data and Information Set) report on the plan, which can tell you whether the plan has special disease programs . for example, for arthritis, mental health, HIV-AIDS, or diabetes treatment.