What to Consider when Choosing a Plan
There are various factors entailed in choosing a health plan. This section will highlight some of the areas you should consider.
What to consider when choosing a plan
Cost of Coverage
Most can agree that cost is a major factor in choosing a health plan. There’s general a monthly cost associated with having coverage. Most employers will contribute a portion of the premium to reduce your cost. It's still important to compare a plan's cost against other things like the provider network, level of service and out of pocket expenses. For example, a plan with low monthly cost may have high deductibles or coinsurance. You may choose to pay for some services out of pocket which may be cheaper than paying for a more expensive plan.
Freedom to see any doctor
Health Maintenance Organizations (HMOs) and Exclusive Provider Organizations (EPOs) generally restrict care to specific lists of providers which you must use. HMOs usually require you to select a Primary Care Physician (PCP) which must refer you to a specialist. You would not have the freedom to choose any doctor. If you would like to select your own doctor and facility for treatment you will need to consider a Preferred Provider Organization (PPO) or a Point-of-Service (POS) plan.
Choosing a Primary Care Physician (PCP) HMOs, EPOs and POS plans usually require you to select a Primary Care Physician (PCP) who coordinates your care. PCP lists generally include internists, pediatricians, general practitioners and family physicians. Your employer may provide you with a PCP list or website where you can access one. Otherwise, you can contact the insurance company directly to request a list. It’s important to note that the PCP will admit you to the hospital where he/she has admitting privileges.
Availability of Doctors
Sometimes managed care plans limit the number of specialist or doctor’s offices are not accepting new patients under your plan. Check the plan's provider directory to make sure the physician is accepting new patients or call his/her office directly.
Geographic Restrictions
In general HMOs and EPOs do not provide coverage to members seeking service outside of the plan's service area, except in an emergency. You’ll want to consider the service area, when you have dependents living outside the area or if you travel a lot. Typically, PPOs will treat the care as any out-of-network service, which generally at a higher expense to the patient.
Maternity Coverage
Most all group health plans cover maternity care but offer different levels of coverage. Many HMOs have specific timeframes on when to send the mothers home from the hospital. Family planning coverage may be limited on some plans. Some plans may cover contraceptives and fertility treatments while others will not.
Service
Service issues should be considered when choosing a health plan. Factors such as customer service, ease of obtaining a doctor’s appointment can affect your decision. Try talking with friends or family or researching the plans service.
Prescription Drug Coverage
Most medical plans cover prescription drugs through a separate program. These plans often have a copayment per prescription and typically offer the option to purchase generic or brand-name drugs. You may be required in some instances to purchase a generic if available. Some plans also have a formulary option which is a list of approved drugs which your doctor must prescribe from. Mail Order is often another option available where you can purchase a few months' supply of a specific drug used for maintenance.
Emergency Coverage
The plan will determine and outline what it considers to be an emergency and how claims will be paid. For example, loss of consciousness, stroke, heart attack. Managed care plans pay for treatment at the closest facility whether or not the hospital is affiliated with your plan. However, if you go to the hospital and it turns out not to be an emergency the plan usually determines whether or not the claim will be paid. PPOs and similar plans typically treat an emergency room visit as an out of network coverage.
Pre-Existing Conditions
A pre-existing condition is a medical condition that started before a person’s health insurance went into effect. HMOs generally cover benefits for pre-existing conditions where PPOs may have limits on what’s covered. The plans will not deny coverage if you have a pre-existing condition, but they would apply a time limit for covering the treatment of it. Health Insurance Portability and Accountability Act (HIPAA) limits the ability of health plans to exclude pre-existing conditions and gives individuals "credit" for prior health coverage. Credit given for the time covered in the prior plan may offset any pre-existing conditions limitations on the new plan.