Determining your Coverage Needs
The below information will provide insight on choosing a medical plan based on your family status.
A young single employee
Young people often do not have concerns with a limited provider directory as they do not have established doctor relationships. If you're healthy, you may be better off choosing the lowest cost plan available. However, you should consider out of pocket expenses that may occur. If you know you will have a lot of medical expenses in the future, the plan with the least amount of out-of-pocket potential may be the best choice. Women should also consider if their OB/GYN doctor is a provider on the plan.
An employee with Young Children
The most common expenses are pediatric visits and immunizations. It may be more cost effective to choose an HMO/POS plan with a low copayment for office visits and prescriptions.
Employee whose spouse has other Coverage
It’s best to base your decision on which coverage is best by comparing the types of coverage available and the costs. If one employer offers plans that provide more choice of higher employer contributions, the employee may prefer one above the other. You should confirm whether or not the employer’s plan has any requirements for the spouse to take their coverage or pay a penalty.
An employee with a dependent living away from home
Most managed care plans only provide emergency care for a student away from home. Since your dependents must be on the same plan, you may need to consider a plan that offers freedom to choose your doctor. A lot of colleges also offer separate coverage just for students.
An employee with health problems
If you or a covered dependent have chronic illnesses or you're expecting to have significant medical expenses for the future, the plan with the least amount of out-of-pocket costs may be the best choice. It’s also important to review the provider list to ensure the established physicians are on the plan. Typically, people with chronic illnesses tend to select plans with freedom to choose your doctor.
An Individual with established medical provider
A Preferred Provider (PPO) or similar plan that allows freedom to choose your providers would be a good choice assuming you can afford the out-of-pocket expenses. If you’re receiving a significant amount of medical care, you may want to choose a lower cost plan or consider switching to doctors that are in the managed care plan.
An employee who is planning to retire soon
If you’re planning to retire at age 65, you will be eligible for Medicare. If you plan to retire before becoming eligible for Medicare, you should consider if your company offers medical coverage to retirees. You may also be eligible for some government subsides. You can also continue coverage through COBRA for 18 months or until you become Medicare eligible, whichever comes first. If you plan to travel after retirement you may want to consider a PPO plan to ensure you have coverage outside the area.
An employee who cannot afford a lot of out-of-pocket expenses
If you are a healthy individual that cannot afford significant out of pocket expense you may want to consider a managed care plan, like an HMO or EPO plan. It may be cheaper to choose a lower cost plan with the risk of some out-of-pocket expenses compared to a higher cost plan.
Employees that use mental health services
Typically, a PPO or POS plan will have more coverage for mental health and/or substance abuse services. However, some managed care plans to offer some mental health services. You will need to check the plan offerings to determine specific limitations and services offered.
An employee who is not sure if they should join a managed care plan
You should consider that joining a managed care program is usually a one-year commitment. If your employer offers other plan options, you can switch health plans during open enrollment or if you move outside a plan's service area. If you are healthy and would like a lower cost plan you should consider a managed care plan to see if it fits your lifestyle. A concern for some people is the issue of "capitation." Capitation is when the medical plan pays a fixed amount of money to a provider each month per covered member. In return, the doctors must provide all care that is necessary. Some people believe this is an incentive for the doctors to withhold care. Proponents say that this payment method provides more efficient care by emphasizing preventive care.