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Questions You Should Ask When Choosing A Health Plan

Ask for an insurance brochure for each plan you're interested in. Read it carefully, before you need to use it. When you start reading over the brochures, take the time to ask yourself some questions. If you can't find the answer, or you don't like the answer you get, move on to another brochure.

Q. Can I see my own primary care physician and specialists?
A. Different types of plans have different rules about which doctors you can see. Ask to see a list of participating doctors. Before you sign up with any plan, ask your doctor if he/she is still affiliated with that plan and can refer you to the specialist of your choice.

Q. If you have an ongoing health problem or condition, how will the plan cover it?
A. Some plans let you see specialists (like orthopedists or allergists) as often and for as long as you want. Others require an authorization that is based on the referral being medically necessary, according to your primary care physician's judgment. If you take medications, prescription coverage is important. Some plans also have different pre-existing condition restrictions. Read the fine print.

Q. Is maternity care covered?
A. Check your plan for coverage of routine check-ups, screening tests and prenatal educational classes.

Q. Does the plan cover preventive care for my children?
A. Plans vary in the coverage of periodic check-ups, immunizations and school physicals.

Q. Do I have to fill out claim forms?
A. As a general rule, when receiving covered services HMOs do not require you to complete forms; neither do Point of Service plans or PPO plans when you are seeing participating providers and have obtained any necessary authorizations. Indemnity plans usually require you to do the claim form paperwork.

Q. Is the least expensive plan always the best buy?
First, start with a plan that offers coverage to match your needs. If all things are equal, only then should you consider the cost. You'll need to look at the monthly premiums versus out-of-pocket costs (deductibles, co-payments) to determine what will cost you the least as you use services during the year.

Q. How can I minimize out-of-pocket expense and maximize coverage to receive the highest level of benefits available?
A. HMO, PPO and POS plans are generally less costly. Within those plans you can minimize out-of-pocket expenses by selecting participating providers and by obtaining referrals and authorizations when necessary.

These examples may assist you in choosing an appropriate health plan:

• You're single, you earn a good wage and at this time, you're the picture of perfect health. Since you rarely see a doctor, your best bet is to choose a plan with a low monthly premium and a higher coinsurance/deductible. But you should also look for a plan with good coverage in areas that are important to you, e.g., routine physicals, emergency care.
• You're a family of four and your oldest is about to start kindergarten. Visits to your pediatrician are frequant. You'll want a plan with low co-payments. Immunizations, check-ups and prescriptions should all be covered expenses. If you already have a pediatrician you like, choose a plan with which he/she is affiliated. You'll also want to make sure a covered immediate care center and hospital are nearby.
• You're married and planning a family. You need a health plan with good maternity and well-child care. Maternity care should include prenatal, delivery and nursery care that begins at the moment of birth. Ideally, you should also plan for unforeseen circumstances like emergency cesarean section and infertility problems. Well-child care will be important to monitor the progress of your healthy baby until 2 years of age. Routine checkups and immunizations should be part of the coverage. Look for a plan with low co-payments since you'll be seeing your doctor a lot. Again, if you have an obstetrician/gynecologist you like, choose a plan with which he/she is affiliated.
• Let's say you're a 40 to 50-year-old with a modest monthly income. You've just been diagnosed with a knee problem for which you'll have to undergo ongoing treatment. You'll need a health plan that lets you see the specialists you want as often as you want to. You'll be taking prescriptions, so you'll want to make sure those are covered expenses. Since your income is modest, low co-payments are important. You may pay a higher premium to get the coverage you want, but the advantages will be worth every cent.

Related Links
Types of insurance plans
Glossary of health-care and insurance terms