CHOOSING
THE RIGHT HEALTH PLAN
PersonalMD.com
Exclusive
Thomas
E. Booth, M.D., M.S.
Vice President, Medical Affairs
PersonalMD.com
Before
choosing a physician or hospital becomes practical, you must enroll
or be enrolled in a health plan. Unless your employer chooses
for you, this can be bewildering. Many employers offer options
that may limit your choices, but still require you to do your
homework. There are many levels of coverage; costs differ widely;
quality varies; you may want to be sure that the physician or
hospital you prefer is included in the plan.
|
Here
is a short checklist of issues to consider:
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- Cost
- Coverage
- Choice
- Access
to specialty care
- Customer
satisfaction
- Measurable
quality
|
One
size doesnt fit all
How
can you begin to make sense of your options? If you have time,
gather report cards on the plans you are considering. Price may
be a factor in yourdecision, but it shouldnt be the only one.
Access to the doctors and hospitals may require paying more but
this may be a price youre willing to pay. You may want to ensure
access to specialty care (policies may vary widely among plans).
Everyones medical needs are different and finding a plan that
matches your needs means that the cheapest plan is not always
the best.
Types
of Health Plans:
Traditional
health insurance
Traditional
indemnity health insurance, which allows complete freedom of choice
in choosing a physician, is an infrequent option in todays health
care marketplace. It is usually expensive, and the right to receive
covered care from any doctor is often offset by the lack of preventive
care, such as screenings, immunizations, and annual physicals.
Like your auto insurance, the higher the premium, the lower the
deductible.
Traditional
planes are often modified with so-called co-insurance features
that provide for partial payment of your medical expenses. An
80/20 plan for example, would pay 80% percent of costs, after
the deductible. Stop loss features may limit your out-of-pocket
expenses once a specific dollar amount is met.
With
stop loss, you might, for example, receive 100 percent reimbursement
after you have paid $2,000 in one year. Unfortunately, this feature
may also include a cap on the lifetime dollar amount of benefits
you can receive for either a single diagnosis or all covered expenses.
Managed
Care
Most
health care consumers now participate in some form of managed
care plan. Choice of physician and hospital is limited to a panel
or network, but preventive care is usually free and out-of-pocket
costs low. Under most plans, a primary care physician directs
treatment. Permission is often required to go out of network or
to receive specialty care.
There
are three major types of managed care plans available:
-
Health
Maintenance Organizations (HMOs)
Most
HMOs receive payment in advance for the health care of a given
number of covered lives. Preventive care and care as needed
is provided by a limited pool of available physicians. If you
receive care from a network or panel doctor, your co-pay is
as low as 5- 10 dollars per visit. If you go outside the plan,
no reimbursement is provided.
- Preferred
Provider Organizations (PPOs)
PPOs usually work with a larger network of physicians in order
to provide more choices for plan members. Physicians may be on
staff at a number of geographically accessible hospitals and be
associated with a number of groups.
Co-payments are also low, again $5-10 dollars per visit, but the
somewhat higher premiums (as compared to HMOs) allow members to
seek treatment out side the network for additional payments, although
not the entire cost. PPOs often do use primary care physicians
as gatekeepers to keep down the costs of providing unlimited specialty
care.
- Point
of Service (POS)
A Point of Service plan combines many of the features of traditional
indemnity insurance with those of HMOs and PPOs. Members may seek
care from any legitimate health care provider whenever it is needed.
Payment is according to a sliding scale that depends on where
and from whom care is sought. Care from physicians or hospitals
on a plans basic list billed at the lowest rate; care from those
on an expanded list cost slightly more; care provided outside
the plan requires members to pick up a higher portion of the cost.
Additional
Options
If
you are eligible for Medicare, a Medicare HMO may be an option.
If you spend part of your time each year in more than one location,
provisions for receiving care outside of the territory covered
by a plan should be considered. You may also wish to consider
long-term or disability insurance, These option will be discussed
in a future article.
Factors
to consider
-
Covered
benefits (the treatments and services the plan reimburses)
-
The
benefits that receive limited reimbursement
-
The
true cost of premiums (including the cost of going outside the
plan)
-
Will the plan allow for a second opinion?
-
The
physicians participating in the plan and any information available
regarding their board certification status, Areport cards,@
and any public record regarding infractions or disciplinary
actions taken against them
-
Does
the National Committee on Quality Assurance (NCQA) accredit
the plan?
-
Are
the hospitals in the plan accredited by the Joint Commission
(JCAHO)
-
A
list of hospitals or other facilities members may use (including,
again Areport cards,@ patient satisfaction surveys, or other
evaluation tools
-
The
plans policies regarding claims and complaints
-
The
level of hospital care provided (access to tertiary or academic
medical centers.
While
the factors you need to consider when choosing a health plan are
many, you should take them one step at a time, since the goal
is to make the best decision possible for your self and for your
family.
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