Questions To Consider When Choosing a Health Plan

It’s that time of year again, when most of us are asked to choose our health plan for next year. It is important to not make this decision lightly. Think of these questions when you’re faced with making a health plan decision.

What is the real total cost?
When asked the cost of their health plan, most people will tell you that it is the amount deducted from their pay. But the true cost includes not only the annual premium, but all costs that you are responsible to pay, based on your benefit design. Consider carefully if there’s a deductible before coverage begins, as well as co-payments and coinsurance costs. Be sure you understand the cost of office visits, emergency services, hospitalization and prescription drugs. Calculate your average annual visits, and then also determine what could be your ‘worst case scenario’, to get a better feel for your potential annual health care cost. It is important to project your annual health care costs by reviewing your current health care situation. For example, consider your average number of doctor vists, prescriptions drugs, preventive and wellness visits, and other health services you routinely use.

Is there catastrophic protection?
Find out if the health plan includes an out of pocket maximum, which will limit your liability for a given calendar or plan year. Be sure to ask if the out of pocket maximum includes the deductible. Typically, once the out of pocket maximum is met, the health plan will pay 100 percent for covered services. In addition to the out of pocket maximum, ask if the plan includes an annual or lifetime benefit maximum? A catastrophic event like a premature birth or cancer treatment could easily use up a low annual or lifetime benefit maximum.

Can I continue to see my doctor(s)?
Many plans today are network plans, meaning you must see a doctor in the health plan’s network for benefits to be covered. Call the health plan(s) or use their Web sites to verify that your doctor(s) is participating - - hard copy directories are out of date as soon as their printed because networks are updated on a daily basis. Also, find out how easy it is to change your doctor with the health plan, if the need arises. You can also call your doctor(s) about the health plan(s) you’re considering, to see how well they work with the physicians on specialty care, services, and claims payment.

How easily can I see a specialist?
Find out if your plan requires a referral from your Primary Care Provider for specialists’ services, or if it’s an open access plan where you can simply schedule an appointment for yourself with a participating doctor. An HMO will typically require referrals, while a PPO or EPO will provide open access. Be sure to ask if you have coverage if you see a non-participating doctor; most PPO’s provide coverage, at more out of pocket expense for you.

Can I go the hospital of my choice?
The same as doctor access, some health plans may not cover services at all hospitals. If there is a hospital you prefer for emergency and planned care, call the health plan to verify that the hospital participates in their network. It is also important to determine if the anesthesiologists that provide services at that hospital are participating in the network. Be sure to ask if they participate for both services provided when admitted, as well as outpatient services (such as x-rays, laboratory, therapies, etc.).

What if I’m traveling out of the area and need medical care?
Ask not only if out of area coverage is provided, but specifically what types of services. Many plans will only cover emergency or urgent care outside of their service area. Some plans may cover all care, but you must use a provider that participates in their national network, or need prior authorization.

Are prescription drugs covered?
Ask if prescription drugs are covered, and if yes what is your cost? Many plans are providing a “tiered” cost structure, meaning you pay a lower copayment for tier 1 medication, and higher copays for tier 2 and tier 3 prescription drugs. Ask if the plan includes a formulary - a list of prescription drugs that will be covered by the plan. Be sure to have the formulary available when visiting your doctor, so they can prescribe the most effective medication to treat your condition at the lowest cost. It is extremely important to understand what medications require prior authorization, or have restrictions attached to them. This should also be defined in the formulary.

Are there limits on any of the covered benefits?
Find out if there are any limitations that apply to the covered benefits. Some typical limitations include visit limits for mental health and substance abuse, as well as for physical therapy. There may also be cost limitations on items such as durable medical equipment.

What additional benefits are covered, besides standard office and hospital care?
Some plans may include coverage for alternative medicine, such as massage therapy or acupuncture. Others may have “value added” benefits for their member, not insured services but discounts to local gyms or health education programs such as smoking cessation or weight loss.

What’s next…

Now that you’ve selected a plan, how do you get the most out of it?

• Read your health care policy and member handbook or other information that you are sent. Keep this information in a handy place, readily accessible if you have questions.
• Check out your health plans Web site. There may be services you can access via the Web, i.e. Provider directories, drug formularies.
• Health insurance carriers have invested in increased service and technology, to meet the informational requirements of today’s health care consumer. They are trained to know your specific plan and how you can get the most out of it. Call your health plan’s customer service department for help.
• If a health plan representative visits your work site, take the time to meet with them.
• Talk to your doctor - - be an active participant in your health care. Ask questions about treatment options, testing, and routine care schedules.
• Keep a file at home for each member of the family that includes immunization records, surgical history and any important health information such as drug allergies.