|
Aspirin-A-Day May Not
Keep Doctor Away
Simplify
your decision about a health care plan.
Changes and Choices
Health care in America
is changing rapidly. Twenty-five years ago, most people in the United
States had indemnity insurance coverage. A person with indemnity
insurance could go to any doctor, hospital, or other provider (which
would bill for each service given), and the insurance and the patient
would each pay part of the bill.
But today, more than
half of all Americans who have health insurance are enrolled in some
kind of managed care plan, an organized way of both providing services
and paying for them. Different types of managed care plans work
differently and include preferred provider organizations (PPOs),
health maintenance organizations (HMOs), and point-of-service (POS)
plans.
You've probably heard
these terms before. But what do they mean, and what are the
differences between them? And what do these differences mean to you?
Overview
This article can help
you make sense of your choices for getting health care insurance:
-
See the questions
and answers on important things you should know when
"Choosing a Plan."
-
To get the most out
of the plan you choose, see the tips in the section "Using
Care."
-
For more help, see
"Sources of Additional Information."
Even if you don't get to
choose the health plan yourself (for example, your employer may select
the plan for your company), you still need to understand what kind of
protection your health plan provides and what you will need to do to
get the health care that you and your family need.
The more you learn, the
more easily you'll be able to decide what fits your personal needs and
budget.
Choosing a Plan
1. What Are My Health
Plan Choices?
Choosing between health
plans is not as easy as it once was. Although there is no one
"best" plan, there are some plans that will be better than
others for you and your family's health needs. Plans differ, both in
how much you have to pay and how easy it is to get the services you
need. Although no plan will pay for all the costs associated with your
medical care, some plans will cover more than others.
Almost all plans today
have ways to reduce unnecessary use of health care—and keep down the
costs of health care, too. This may affect how easily you get the care
you want, but should not affect how easily you get the care you need.
Plans change from year
to year, so you should carefully consider each plan, using the
questions outlined in this booklet. If you get health insurance where
you work, you should start with your employee benefits office. Its
staff should be able to tell you what is covered under the plans
available. You can also call plans directly to ask questions.
Health insurance plans
are usually described as either indemnity (fee-for-service) or managed
care. These types of plans differ in important ways that are described
below. With any health plan, however, there is a basic premium, which
is how much you or your employer pay, usually monthly, to buy health
insurance coverage. In addition, there are often other payments you
must make, which will vary by plan. In considering any plan, you
should try to figure out its total cost to you and your family,
especially if someone in the family has a chronic or serious health
condition.
Indemnity and managed
care plans differ in their basic approach. Put broadly, the major
differences concern choice of providers, out-of-pocket costs for
covered services, and how bills are paid. Usually, indemnity plans
offer more choice of doctors (including specialists, such as
cardiologists and surgeons), hospitals, and other health care
providers than managed care plans. Indemnity plans pay their share of
the costs of a service only after they receive a bill.
Managed care plans have
agreements with certain doctors, hospitals, and health care providers
to give a range of services to plan members at reduced cost. In
general, you will have less paperwork and lower out-of-pocket costs if
you select a managed care type plan and a broader choice of health
care providers if you select an indemnity-type plan.
Over time, the
distinctions between these kinds of plans have begun to blur as health
plans compete for your business. Some indemnity plans offer managed
care-type options, and some managed care plans offer members the
opportunity to use providers who are "outside" the plan.
This makes it even more important for you to understand how your
health plan works.
Besides indemnity plans,
there are basically three types of managed care plans: PPOs, HMOs, and
POS plans.
Indemnity Plan
With an indemnity plan
(sometimes called fee-for-service), you can use any medical provider
(such as a doctor and hospital). You or they send the bill to the
insurance company, which pays part of it. Usually, you have a
deductible—such as $200—to pay each year before the insurer starts
paying.
Once you meet the
deductible, most indemnity plans pay a percentage of what they
consider the "Usual and Customary" charge for covered
services. The insurer generally pays 80 percent of the Usual and
Customary costs and you pay the other 20 percent, which is known as
coinsurance. If the provider charges more than the Usual and Customary
rates, you will have to pay both the coinsurance and the difference.
The plan will pay for
charges for medical tests and prescriptions as well as from doctors
and hospitals. It may not pay for some preventive care, like checkups.
Managed Care
Preferred Provider
Organization (PPO). A PPO is a form of managed care closest to an
indemnity plan. A PPO has arrangements with doctors, hospitals, and
other providers of care who have agreed to accept lower fees from the
insurer for their services. As a result, your cost sharing should be
lower than if you go outside the network. In addition to the PPO
doctors making referrals, plan members can refer themselves to other
doctors, including ones outside the plan.
If you go to a doctor
within the PPO network, you will pay a copayment (a set amount you pay
for certain services—say $10 for a doctor or $5 for a prescription).
Your coinsurance will be based on lower charges for PPO members.
If you choose to go
outside the network, you will have to meet the deductible and pay
coinsurance based on higher charges. In addition, you may have to pay
the difference between what the provider charges and what the plan
will pay.
Health Maintenance
Organization (HMO). HMOs are the oldest form of managed care plan.
HMOs offer members a range of health benefits, including preventive
care, for a set monthly fee. There are many kinds of HMOs. If doctors
are employees of the health plan and you visit them at central medical
offices or clinics, it is a staff or group model HMO. Other HMOs
contract with physician groups or individual doctors who have private
offices. These are called individual practice associations (IPAs) or
networks.
HMOs will give you a
list of doctors from which to choose a primary care doctor. This
doctor coordinates your care, which means that generally you must
contact him or her to be referred to a specialist.
With some HMOs, you will
pay nothing when you visit doctors. With other HMOs there may be a
copayment, like $5 or $10, for various services.
If you belong to an HMO,
the plan only covers the cost of charges for doctors in that HMO. If
you go outside the HMO, you will pay the bill. This is not the case
with point-of-service plans.
Point-of-Service
(POS) Plan. Many HMOs offer an indemnity-type option known as a
POS plan. The primary care doctors in a POS plan usually make
referrals to other providers in the plan. But in a POS plan, members
can refer themselves outside the plan and still get some coverage.
If the doctor makes a
referral out of the network, the plan pays all or most of the bill. If
you refer yourself to a provider outside the network and the service
is covered by the plan, you will have to pay coinsurance.
Primary Care Doctors
Your primary care doctor
will serve as your regular doctor, managing your care and working with
you to make most of the medical decisions about your care as a
patient. In many plans, care by specialists is only paid for if your
are referred by your primary care doctor.
An HMO or a POS plan
will provide you with a list of doctors from which you will choose
your primary care doctor (usually a family physician, internists,
obstetrician-gynecologist, or pedicatrician). This could mean you
might have to choose a new primary care doctor if your current one
does not belong to the plan.
PPOs allow members to
use primary care doctors outside the PPO network (at a higher cost).
Indemnity plans allow any doctor to be used.
2. Where Do I Get
These Health Plans?
Group Policies
You may be able to get
group health coverage—either indemnity or managed care—through
your job or the job of a family member.
Many employers allow you
to join or change health plans once a year during open enrollment. But
once you choose a plan, you must keep it for a year. Discuss choices
and limits with your employee benefits office.
Individual Policies
If you are self-employed
or if your company does not offer group policies, you may need to buy
individual health insurance. Individual policies cost more than group
policies.
Some
organizations—such as unions, professional associations, or social
or civic groups—offer health plans for members. You may want to talk
to an insurance broker, who can tell you more about the indemnity and
managed care plans that are available for individuals. Some States
also provide insurance for very small groups or the self-employed.
Medicare
Americans age 65 or
older and people with certain disabilities can be covered under
Medicare, a Federal health insurance program.In many parts of the
country, people covered under Medicare now have a choice between
managed care and indemnity plans. They also can switch their plans for
any reason. However, they must officially tell the plan or the local
Social Security Office, and the change may not take effect for up to
30 days. Call your local Social Security office or the State office on
aging to find out what is available in your area.
Medicaid
Medicaid covers some
low-income people (especially children and pregnant women), and
disabled people. Medicaid is a joint Federal-State health insurance
program that is run by the States.
In some cases, States
require people covered under Medicaid to join managed care plans.
Insurance plans and State regulations differ, so check with your State
Medicaid office to learn more.
Pre-Existing
Conditions
A pre-existing condition
is a medical condition diagnosed or treated before joining a new plan.
In the past, health care given for a pre-existing condition often has
not been covered for someone who joins a new plan until after a
waiting period. However, a new law—called the Health Insurance
Portability and Accountability Act—changes the rules.Under the law,
most of which goes into effect on July 1, 1997, a pre-existing
condition will be covered without a waiting period when you join a new
group plan if you have been insured the previous 12 months. This means
that if you remain insured for 12 months or more, you will be able to
go from one job to another, and your pre-existing condition will be
covered—without additional waiting periods—even if you have a
chronic illness.
If you have a
pre-existing condition and have not been insured the previous 12
months before joining a new plan, the longest you will have to wait
before you are covered for that condition is 12 months.
To find out how this new
law affects you, check with either your employer benefits office or
your health plan.
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:
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?
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.
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 provisection 6.).
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.
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. For doctors, see "Tips on
Choosing a Doctor."
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 (see
"Sources of Additional Information"). 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
andexperience.
-
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.
|
