Health Plan Questions to Ask
Services
Look at the services offered by each plan to see if they meet your
needs.
- 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?
- How does
the plan treat preexisting conditions?
- Is there
a lifetime cap on the cost of care for chronic conditions?
- Will the
plan cover treatments that are experimental? And how does it decide
what is or is not experimental?
- What can
you do if you disagree with a plan's decision on medical care
or coverage?
Benefits
Think about whether
the plan will meet your needs. Are you starting a family, or retiring?
Does anyone in your family have a chronic health condition or disability?
Which of the following does the plan cover?
- Care by
specialists?
- Hospitalization
and emergency care?
- Prescription
drugs?
- Vision
care?
- Dental
services?
- 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?
- Immunizations
for children?
- Health screenings,
such as breast exams and Pap smears for women?
- Does the
plan help people who want to quit smoking?
Choice
of provider
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.
An HMO plan
will provide you with a list of doctors from which you will choose
your primary care doctor (usually a family physician, internist,
obstetrician-gynecologist, or pediatrician). This could mean you
might have to choose a new primary care doctor if your current one
does not belong to the plan. 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.
PPOs allow members
to use doctors outside the PPO network (at a higher cost). Indemnity
plans allow any doctor to be used.
- 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
Find out how the plan provides care outside the service
areas and what you must do to get care. This is especially important
if you travel often, are away from home for long periods, or have
family members away at school.
- 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. 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.
- 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.
- What types
of care or services will the plan not pay for? These are called
"exclusions.")
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.
- Is the
managed care plan accredited?
- Does the
plan review the qualifications of doctors before they are added
to the plan?
- How does
the plan review its own services, and has it made changes to correct
problems?
- How does
the plan resolve member complaints?
- Has the
managed care plan surveyed its members about their health care
experiences? If so, can you have a report of the survey results?
Access
to care
Learning what you can expect from your health plan and how it works
are key steps to getting the care you need. So be sure and find
out the following.
- When are
the offices open? What if I need care after hours?
- How do I
make appointments? How quickly can I expect to be seen for illness
or for routine care?
- If I need
lab tests, are they done in the doctor's office or will I be sent
to a laboratory?
- Will most
of my appointments be with the primary care doctor? Will nurse
practitioners or physician's assistants sometimes give care as
well?
- Is there
an advice hotline? Some plans have toll-free phone services that
help members decide how to handle a problem that may not require
a doctor's visit.
Hospitalization
The time to find out what rules your plan has on hospital care is
before you need it. Unless it is a medical emergency, your health
plan or primary care doctor will probably have to give advance approval
(preadmission certification) for you to go to the hospital. Otherwise,
the cost of your hospital care may not be covered.
- What hospitals
are part of the plan network?
- Is there
a limit on how long I can stay in the hospital?
- Who decides
when I am to be discharged?
- Will needed
follow-up care, such as nursing home or home health care, be covered
by the plan?
- If I have
a serious medical problem, will the plan provide someone to oversee
care and make sure my needs are met?
- Will the
plan cover a second doctor's opinion on whether surgery or another
treatment is needed. Are second opinions encouraged or required?
Who pays?
Emergency
or urgent care
If you have a true medical emergency, you should go to the nearest
hospital as fast as possible. It is important for you to know what
kind of medical problems are defined as emergencies and how to arrange
for ambulance service, if needed. Most plans must be notified within
a certain time after emergency admission to a hospital. If the hospital
is not part of the plan network, you may be transferred to a network
hospital when your condition is stable. Ask these questions:
- How does
the plan define "emergency care?" What conditions or injuries
are considered emergencies?
- How does
the plan handle "urgent care" after normal business hours? Urgent
care is for problems that are not true emergencies but still need
quick medical attention. Check with your plan to find out what
it considers to be urgent care. Examples may include sore throats
with fever, ear infections, and serious sprains.
- Can you
call your primary care doctor or the plan's hotline for advice
about what to do? The plan may also have urgent care centers for
members.
- How do I
get urgent care or hospital care if I am out of the area? How
must I tell the plan and how soon after I get the care?
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