CHOOSING A HEALTH PLAN

For individuals choosing a health plan during open enrollment periods this fall, Consumers Union, the publisher of Consumer Reports, has developed a list of questions to ask before signing up with any particular plan. While no list of recommendations can fully address the issues that consumers face with HMOs, the following tips are an attempt to provide you with guidance as you make this important decision.

While choosing a plan may seem daunting, if you have this choice, consider yourself lucky. More than forty million Americans don't have any form of health insurance. Others who have insurance don't have any choice about which plan will provide them with care. So take the time to think carefully about your needs and your options, and then make a well-considered decision.

ASSESS YOUR FAMILY'S NEEDS. MAKE A FAMILY INVENTORY OF MEDICAL NEEDS AND LIKELY USES OVER THE NEXT YEAR.

· Do you or a family member require specialists or specific treatments?
· Does someone in your family need chronic care or costly medication?
· Will the location of the doctors make transportation an issue?
· Do you prefer to use a nearby hospital? Not every plan uses the nearest hospital.
· Do you or family members require mental health benefits?
· What other factors are important to you?

…a specific doctor?
…direct access to a specific gynecologist or pediatrician?
…a clinic that is open in the evenings?
…no or low drug co-payments?

· Do you need ancillary services such as vision, dental or medical equipment? Will you require home health coverage?
· While you cannot predict all your needs, it pays to make a list of all the services you expect to need in the coming year and then evaluate each plan according to your own list.

IF YOU NEED SPECIAL TREATMENT, YOU SHOULD CONDUCT EXTRA RESEARCH.

The general health plan brochures you receive from your benefits office will not answer specific questions. Ask your benefits office to find out if and exactly how a plan will cover your special needs, or call the plan yourself and ask about "evidence of coverage" to determine whether you're covered. Find out before you sign up.

TAKE A GOOD LOOK AT YOUR FINANCES.

Don't choose a plan with high out-of-pocket expenses if you can't pay for them. If possible, pick a plan that will provide you the services you need at a price you can realistically afford.

ONCE YOU'VE ASSESSED YOUR OWN NEEDS AND RESOURCES, COLLECT INFORMATION ON THE PLANS.

• Gather information from your employer's benefits counselor.
  
  
• Ask your doctor about the plan you're considering.
  
  
• Ask the plan about its accreditation. Find out whether the plan has been accredited by the National Committee for Quality Assurance (NCQA.) [Web site: www.ncqa.org]. However, be aware the NCQA uses data that has been collected by the plans themselves, so while their information can be a guide, accreditation is not a guarantee of excellence.
  
  
• Check out possible out-of-pocket expenses. When you consider a point-of-service (POS) plan (an HMO with an option to go to an out-of-plan doctor), see what portion of a doctor's fees the plan will pay. Although rates for these POS plans are higher, it is a valuable option that Consumers Union recommends.
  
  
• Be aware that Preferred Provider Organizations (PPOs), loose networks of doctors that also allow members to receive care outside the network, usually cost more than HMOs, but offer the consumer more choice. This may be the best choice for people with special needs.
  
  
• Ask the plans you are considering about specialists. How easy is it for your primary care doctor to give referrals to specialists? Ask each HMO you're considering to give you a list of specialists. Determine whether you like the lists, or whether the plans are lacking in a specialty you might really need.
  
  
• If you choose an HMO, you must also choose a primary care physician. For most HMOs, your selection will assign you to a particular medical group. Be sure you understand the rules of the group, especially regarding choice of hospitals and specialists. You are probably limited to specialists within the medical group.
  
  
• Ask the plans whether they have experienced major changes in the numbers of doctors or networks included. Be sure that the doctors you like are accepting new patients.
  
  
• Ask the plans about coverage for medication and chronic conditions. If you are currently on medication, will the plan you're considering approve the regimen you're on? If you suffer from a chronic condition such as asthma or diabetes, what kinds of outreach and monitoring does the plan have?
  
  
• In California, you may get additional information about health plans from two different agencies, depending on the type of plan you are considering. The Department of Corporations (DOC) oversees the state's HMO plans, which are the majority of California plans. The Department of Insurance oversees the state's indemnity plans, such as traditional insurance and PPOs. Ask the DOC for the latest summary of the medical survey on the plans you are considering. These can be obtained free of charge by calling: (213) 576-7505 or (916) 445-7719. You may contact the Department of Insurance Consumer Services at (800) 927-4357.
  
  
• Other information on choosing a plan is available from the Pacific Business Group on Health, at phone number (415) 281-8660 (California only) or web site: www.healthscope.org; or the Public Employees Retirement System, at web site: www.calpers.ca.gov (California only)

IF YOU'VE ALREADY ENROLLED IN A MANAGED CARE PLAN…

· Be prepared to speak up and write letters to advocate for proper care.

· Be ready to switch doctors. If you're unhappy with your care or you don't like the doctor, most plans make it reasonably easy to switch.

· Prepare an escape fund. You may need to use services outside the plan if you can't get the care you need with the plan. If your health is at stake, financial constraints shouldn't keep you from doing what you must.

· Be a squeaky wheel. Complain to the HMO when you don't get a referral or an appointment that you think you need. Learn about the plan's grievance procedure and, if necessary, use it.

· If you're enrolled through your employer, complain to the benefits manager if you're unhappy with the plan. Some employers have strong purchasing power.

· To lodge a complaint about an HMO in California call the DOC complaint hotline at (800) 400-0815. To lodge a complaint about indemnity plans, call the Department of Insurance at (800) 927-4357.

In its August 1999 issue, Consumer Reports magazine rated 54 HMOs throughout the country, based on survey data from 19,000 subscribers. Individual copies of that study are available to the public at a charge of $7.75 by calling 1-800-766-9988 and requesting reprint #9876. Information on bulk reprints (10 copies or more) can be obtained by writing to Reprints and Permission, Consumers Union, 101 Truman Avenue, Yonkers, New York 10703-1057. (News media can receive copies by contacting Robin Kane at 415-431-6747.)

Consumers Union's West Coast Regional Office
September 1999

Consumers Union, publisher of Consumer Reports, is an independent, nonprofit testing and information organization, serving only the consumer. We are a comprehensive source of unbiased advice about products and services, personal finance, health, nutrition, and other consumer concerns. Since 1936, our mission has been to test products, inform the public, and protect consumers.

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