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10 Questions to Consider
Before Choosing a Health Plan

By Critical Condition producer Marc Shaffer

Choosing a health plan can either be very simple — your employer only offers a single option, or very difficult — you have many choices and must figure out the best one. People are all different, and there is no single best choice for everyone. Your health condition, personal tastes, priorities and ability to pay all affect your selection. Here are 10 basic questions as well as some useful web site links that will help you make an informed decision.

1. How important is access to special or particular care?

Points to consider:

  • If you have diabetes, cancer or asthma, will your preferred medications be covered or will you be forced to use only the drugs listed on the health plan's "formulary"? Will your medical supplies (syringes, test strips, insulin pumps, inhalers, and the like) be covered?

  • If you have a pre-existing condition, will it be covered?

  • Will experimental treatments be covered?

  • Is there a lifetime cap for expenditures on all of your treatments?

  • Will you be guaranteed access, at your doctor's recommendation, to the best or most respected physicians, specialists, specialty clinics, rehabilitation hospitals, and home nursing care agencies in your area? Or does the health plan have a limited list of providers?

  • If you have mental health problems, is there a limit on how many visits are covered or how much care you can receive? Does the health plan require that care be given in certain pre-approved facilities, such as mental hospitals or licensed community clinics, or can it be given in a psychiatrist's or psychologist's office?

  • Do you want or need other coverage, such as eye care or dentistry?

2. How important is the quality of a particular plan?

Points to consider:
Quality is the factor most cited by Americans in choosing a health plan. Quality reviews on most health plans are available. Quality can be measured generally in terms of three components:

  • Patient service (convenience, ease of access, availability of doctors and treatments);

  • Care "inputs" (preventive measures such as mammograms, vaccinations, annual physicals, tests given etc.); and

  • Patient outcomes or medical performance (how many patients out of 100 survive surgery, how many return to normal life after a stroke, etc.).

Many states, businesses, health plans, Medicare, and the National Committee on Quality Assurance have measures of quality in terms of service and inputs. Very few states or institutions measure their actual performance, though some performance statistics are available in states like New York and Pennsylvania.

More broadly, states, businesses, health plans and the Federal Government's personnel office are turning to a survey called Consumer Assessment of Health Plans (CAHPS) which tells them what members think of the plans they are in. CAHPS was designed by national experts in healthcare quality through funding from the Agency for Health Care Policy and Research.

The National Committee on Quality Assurance (NCQA) has added CAHPS survey questions to its own member satisfaction survey. Call 1-888-275-7585 or 1-800-839-6487 to find out if a health plan is accredited and to receive an accreditation report summarizing the NCQA findings. Or check the NCQA's web site.*

The monthly magazine Consumer Reports and national newsmagazines like Newsweek and U.S. News and World Report also produce report cards. These are imperfect measures to be sure, but better than nothing.

3. How important is convenience and service?

Points to consider:

  • Are the healthcare providers, hospitals and clinics conveniently located?

  • Are they open at off-hours and on weekends?

  • Is it easy to get appointments quickly?

  • Will you be able to see your personal physician every time, or do you have to see any available doctor — and if so how often will you get to see your personal physician?

  • Is it easy to get through on the telephone?

  • Are there long waits in pharmacies and waiting rooms?

  • Can you have all your needs met easily in one location, or must you travel to several facilities for care?

Some plans may give you access to a broader choice of hospitals and doctors. Others, particularly group model HMOs, restrict services to their own facilities that may be less conveniently located. An advantage of the group model plan, however, is that such plans often have all services located in one place and their doctors and facilities are usually organized to work together and provide integrated, coordinated care.

4. How accessible is care?

Points to consider:

  • In order to see a specialist, to have a special test and to get specialized care, must you get pre-approval from the HMO?

  • In order to see a specialist, must you get a referral from your primary care provider?

  • Is your primary care provider's income increased or decreased by the amount of care he or she provides, the number of lab tests ordered by the number of times he or she refers patients to specialists? (This practice is broadly called "capitation" and it may cause primary care doctors to limit ordering extra care, tests or treatment.)

5. How important is choice of provider?

Points to consider:

  • Many people feel very strongly that they must have a very wide selection of physicians and specialists to choose from. If you feel this way, join a plan that has a large provider panel to choose from or that may charge more for complete freedom of choice, but be sure to call around to make sure the most desirable doctors are actually taking new patients and will accept the particular coverage you are considering.

  • If you have a personal physician, pediatrician, gynecologist, or other regular doctor that you want to continue seeing, be certain that the plan you choose gives you access to her or him.

Be careful not to confuse "choice" with "quality." Some of the health plans that get the highest quality ratings are those which limit your choice of providers to their pre-screened and pre-selected panels of physicians and facilities, which may actually offer a fairly wide selection. In fact, many quality experts believe that in order to improve the quality of care, physician-led HMOs must coordinate and control care among a smaller pool of physicians. The more open health plans, experts say, often allow wider choice but that can lead to fragmented and uncoordinated health care because the doctors are not working for a centralized organization that oversees care.

6. How important is cost?

If finances are a key consideration, then you may want to choose a less expensive plan. But be careful to read the fine print of the health plans you are considering so that you do not accept a low premium plan that will limit or deny you some of the most important benefits and financial coverage that you will need if you become seriously ill, injured or disabled. You may pay less up front in terms of premium and office visit co-pays, but you may be in financial trouble if there are caps on coverage of high deductibles and you contract a serious chronic illness such as diabetes, cancer or AIDS.

Also, carefully assess what option is the best value. If you plan to have a few very expensive procedures done each year, you'll do best with a low-deductible, high-co-pay plan. If you see the doctor a lot, say with a new baby, you may save more money with a higher deductible but lower co-pay.

7. How reliable is the health plan?

Points to consider:

  • Has the plan been around for a long time, and does it appear likely to remain in the community for years to come?

  • Do doctors give it high marks?

  • Does the plan stay loyal to its providers? Or does it constantly turn over physicians — meaning you'll have to search for a new doctor regularly.

  • Is there a large turnover among the plan's membership, especially those patients (members) who need costly long-term care? Such frequent member turnover may be a sign that members with serious illnesses have trouble getting that health plan to pay for their health care.

8. How good are the appeals processes in a plan?

Points to consider:

  • If there is a dispute over coverage or access to particular kinds of care, or if you feel you've been injured by a plan's actions, are there good avenues of recourse available?

  • Are there clear time limits within which the health plan must respond to appeals? (For example, a stroke victim can require major decisions on rehabilitation to be acted upon within 72 hours.)

  • Does your state or your community have an appeals process which provides public oversight and review of health plan performance?

  • Is there a consumer hotline in your state and community to which you can make appeals if you have a dispute with your health plan or with a medical provider?

9. What are the emergency care provisions of the plan?

Points to consider:

  • Does the health plan permit you to be taken to any emergency room in any hospital or clinic in your area, or does it require that you be taken by your family, friends or an ambulance only to specific emergency rooms on its approved list of hospitals?

  • Is the hospital nearest to your residence on your health plan's approved list of emergency facilities to which you can be taken in an emergency?

  • Is the hospital of your choice on your health plan's approved list of facilities to which you can be taken in an emergency?

  • Does your health plan require that the hospital emergency room get prior approval from the plan before providing you with specific emergency services?

  • Does your health plan require that it give specific authorization before emergency room doctors or staff can admit you to a hospital?

10. If you travel, how do you get care when outside your local service area?

Points to consider:

  • If your health plan is a local or regional plan, will it cover your treatment in distant locations when you are traveling away from your home region? If so, does it impose any limitations on the care that you can receive? For example, does it permit you to receive only emergency care while you are traveling, but disallow you from being reimbursed for other care?

  • If your health plan is a nationwide health insurer, does it cover you for treatment in remote locations (such as overseas)? Can you get care anywhere in the United States, or does the health plan require you to travel to the nearest facility in its own network of approved facilities?

  • If your health plan does provide coverage while you are traveling, does it have any limits on what doctors, clinics and hospitals can give you care?

  • Does your health plan require you to obtain pre-approval from the health plan before getting care while you are traveling outside of your home area?

Helpful Web Sites

The Agency for Healthcare Quality and Research, from which much of this material is adapted, is a huge source of good information. Contact them at Executive Office Center, Suite 601, 2101 East Jefferson Street, Rockville, MD 20852 or check out their website at www.ahcpr.gov. See "Consumer Health."

Consumers' Union's website is at www.consumersunion.org

*The National Committee on Quality Assurance website can be found at www.ncqa.org. For health plan accreditation status information and reports, see www.ncqa.org/Pages/Programs/Accreditation/accreditation.htm.



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