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Choosing and Using A Health Plan

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3. What Plan Benefits Are Offered?

Most plans provide basic medical coverage, but the details are what counts. The best plan for someone else may not be the best plan for you. For each plan you are considering, find out how it handles:

  • Physical exams and health screenings.
  • Care by specialists.
  • Hospitalization and emergency care.
  • Prescription drugs.<
  • Vision care.
  • Dental services.

Also ask about:

  • Care and counseling for mental health.

  • Services for drug and alcohol abuse.

  • Obstetrical-gynecological care and family planning services.

  • Ongoing care for chronic (long-term) diseases, conditions, or disabilities.

  • Physical therapy and other rehabilitative care.

  • Home health, nursing home, and hospice care.

  • Chiropractic or alternative health care, such as acupuncture.

  • Experimental treatments.

Some plans offer members health education and preventive care, but services differ. Ask questions such as:

  • What preventive care is offered, such as shots for children?

  • What health screenings are given, such as breast exams and Pap smears for women?

  • Does the plan help people who want to quit smoking?

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4. What Is Most Important to Me in a Plan?

In choosing a plan, you have to decide what is most important to you. All plans have tradeoffs. Ask yourself these questions:

  • How comprehensive do I want coverage of health care services to be?

  • How do I feel about limits on my choice of doctors or hospitals?

  • How do I feel about a primary care doctor referring me to specialists for additional care?

  • How convenient does my care need to be?

  • How important is the cost of services?

  • How much am I willing to spend on premiums and other health care costs?

  • How do I feel about keeping receipts and filing claims?

You might also want to think about whether the services a plan offers meet your needs. Call the plan for details about coverage if you have questions. Consider:

  • Life changes you may be thinking about, such as starting a family or retiring.

  • Chronic health conditions or disabilities that you or family members have.

  • If you or anyone in your family will need care for the elderly.

  • Care for family members who travel a lot, attend college, or spend time at two homes.

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5. How Do I Compare Health Plans?

After you review what benefits are available and decide what is important to you, you can compare plans. Many things should be considered. These include services offered, choice of providers, location, and costs. The quality of care is also a factor to think about.

Services

Look at the services offered by each plan. What services are limited or not covered? Is there a good match between what is provided and what you think you will need? For example, if you have a chronic disease, is there a special program for that illness? Will the plan provide the medicines and equipment you may need?

Find out what types of care or services the plan won't pay for. These usually are called exclusions.

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.

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?

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?

Costs

No health insurance plan will cover every expense. To get a true idea of what your costs will be under each plan, you need to look at how much you will pay for your premium and other costs.

  • Are there deductibles you must pay before the insurance begins to help cover your costs?

  • After you have met your deductible, what part of your costs are paid by the plan?

  • Does this amount vary by the type of service, doctor, or health facility used?

  • Are there copayments you must pay for certain services, such as doctor visits?

  • If you use doctors outside a plan's network, how much more will you pay to get care?

  • If a plan does not cover certain services or care that you think you will need, how much will you have to pay?

  • Are there any limits to how much you must pay in case of major illness?

  • Is there a limit on how much the plan will pay for your care in a year or over a lifetime? A single hospital stay for a serious condition could cost hundreds of thousands of dollars.

You can't know in advance what your health care needs for the coming year will be. But you can guess what services you and your family might need. Figure out what the total costs to your family would be for these services under each plan.

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6. How Do I Find Out About Quality?

Quality is hard to measure, but more and more information is becoming available. There are certain things you can look for and questions you can ask. Whatever kind of plan you are considering, you can check out individual doctors and hospitals.

Many managed care plans are regulated by Federal and State agencies. Indemnity plans are regulated by State insurance commissions. Your State Department of Health or insurance commission can tell you about any plan you are interested in.

You can also find out if the managed care plan you are interested in has been "accredited," meaning that it meets certain standards of independent organizations. Some States require accreditation if plans serve special groups, such as people in Medicaid. Some employers will only contract with plans that are accredited.

Several national organizations review and accredit plans and institutions. You can contact these organizations to see if a plan you are considering, or an institution in the plan, is accredited.

Another approach is to ask the plan how it ensures good medical care. Does the plan review the qualifications of doctors before they are added to the plan? Plans are supposed to review the care that is given by their doctors and hospitals. How does the plan review its own services, and has it made changes to correct problems? How does the plan resolve member complaints?

Some managed care plans survey members about their health care experiences. Ask the plan for a report of the survey results.

Some plans and independent organizations are also beginning to produce "report cards." These reports often include satisfaction survey results and other information on quality, such as if a plan provides preventive care (for example, shots for children and Pap smears for women) or if the plan follows up on test results. Report cards may also include information on how many members stay in or leave the plan, how many of the plan's doctors are board certified, or how long you may have to wait for an appointment.

Report cards can only give you an idea of how a plan works and may not give a full picture of a plan's quality. Ask plans if their activities have been reported in report cards developed by outside groups (business or consumer organizations).

Also keep any eye out for magazine articles that rate health plans.

Finally, you can talk to current members of the plan. Ask how they feel about their experiences, such as waiting times for appointments, the helpfulness of medical staff, the services offered, and the care received. If there are programs for your particular condition, how are the patients in it doing?


Tips On Choosing A Doctor

Your doctor will be your partner in care, so it is important to choose carefully from the doctors available to you. In some managed care plans, you will generally be limited to choosing from only certain doctors; in other plans, some doctors may be "preferred," which means they are part of a network and you will pay less if you use them. Ask your plan for a list or directory of providers. The plan may also offer other help in choosing.

You can ask doctors you know, medical societies, friends, family, and coworkers to recommend doctors. You may also contact hospitals and referral services about doctors in your area.

Once you have the names of doctors who interest you, make sure they are accepting new patients. Here's how to check doctors out:

  • Ask plans and medical offices for information on their doctors' training and experience.

  • Look up basic information about doctors in the Directory of Medical Specialists. available at your local library. This reference has up-to-date professional and biographic information on about 400,000 practicing physicians.

  • Use "AMA Physician Select," which is the American Medical Association's free service on the Internet for information about physicians (http://www.ama-assn.org/aps/amahg.htm).

You may also want to find out:

  • Is the doctor board certified? Although all doctors must be licensed to practice medicine, some also are board certified. This means the doctor has completed several years of training in a specialty and passed an exam. Call the American Board of Medical Specialties at 800-776-2378 for more information.

  • Have complaints been registered or disciplinary actions taken against the doctor? To find out, call your State Medical Licensing Board. Ask Directory Assistance for the phone number.

  • Have complaints been registered with your State department of insurance? (Not all departments of insurance accept complaints.) Ask Directory Assistance for the phone number.

Once you have narrowed your search to a few doctors, you may want to set up "get acquainted" appointments with them. Ask what charge there might be for these visits, if any. Such appointments give you a chance to interview the doctors—for example, to find out if they have much experience with any health conditions you may have.

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