It used to be that selecting a health plan was a relatively simple process. Your employer offered to enroll you in the company plan, and once you signed on the dotted line, most of your health care expenses were covered.
But times have changed. For many people, choosing health insurance feels like a high-wire act, where even a single misstep might send them into a free fall if illness strikes.
Managed care is still the name of the game for many consumers, forcing them to make sense of the alphabet soup of health care delivery systems, most commonly HMOs (health maintenance organizations) and PPOs (preferred provider organizations).
An HMO offers a kind of one-stop shopping for health care. HMOs provide a comprehensive health care services on a pre-paid basis to its members. An HMO member selects a primary care physician as his or her personal doctor and agrees to use only doctors and hospitals affiliated with the HMO. In return, an HMO minimizes out-of-pocket expenses members have to pay when they see doctors. There are usually no deductibles and very small co-payments. PPOs do not require members to select a primary care physician. However, the PPO members receive financial incentives to use doctors and hospitals affiliated with the PPO. Generally, there are no deductibles and small co-payments. A PPO may pay 50 to 70% of the cost of services provided by a non-PPO affiliated doctor or hospitals.
Being in a managed care plan is different from traditional health insurance. Traditional health insurance pays doctors from each service provided, known as fee-for-service. There are fewer restrictions on what doctors and hospitals you may choose. However, you will pay more in premiums, deductibles and other expenses that with a managed care plan. Preventative services are usually not covered.
"Managed care health plans emphasize preventative health care and a strong relationship with your primary care physician," says Dr. Joseph Hindo, internal medicine physician member of the Silver Cross Managed Care Organization for over 15 years. "With HMO plans, a primary care physician, like myself, manages your referrals to specialists and other health services." -- Back to top.
Even if you're among the majority of Americans who obtain your health insurance through your employer, you'll need to choose from among the plans being offered, and make sense of the scope of the coverage and how much you'll be paying out-of-pocket.
"As a result, you need to practice your own "planned patienthood," says Dr. Hindo. "Comparison-shop to make sure you're selecting the right coverage for you and your family. The average person spends only about 16 minutes looking at health-plan materials before he or she makes a decision. It would be worth spending more time than that." -- Back to top.
Guidelines for Optimal Coverage
To help you navigate successfully through the health-plan obstacle course, Dr. Hindo suggests some key issues to examine: -- Back to top.
Is your own doctor part of the plan, and does she expect to stay on the plan? Before selecting your coverage, choose your physician, and find out what plans she participates in. If you don't already have a primary care physician, you may want to contact the Silver Cross Physician Referral Service at 1-888-660-HEAL (4325). Here you can find information on a doctor's philosophy of practice, where the he received his training and also his office hours. If you already have a doctor who you want to keep seeing, ask her (or her office staff), "I'm thinking of committing myself for the next year to a plan that you're on; is it safe to assume that you're going to continue participating in it for the entire year?" -- Back to top.
Do you need to see specialists? If you have a chronic health problem—like diabetes or allergies—or if you develop a serious condition that should be treated by a cardiologist or gastroenterologist, for example, make sure that you can receive care from such a specialist. Because your choice of doctors is limited to those who participate in the plan, you want to choose a managed care organization that gives you an abundance of physicians to choose from-like the Silver Cross Managed Care Organization, which offers a choice of over 200 primary and specialty physicians." -- Back to top.
Is medical care available close to home? Check the locations of physicians' offices and hospitals that are part of the plan, and make sure they're as convenient as possible. The Silver Cross Managed Care Organization offers physicians in 25 locations throughout the southwest suburbs and is affiliated with Silver Cross Hospital-one of the top 100 hospitals in the nation according to Thomson Reuters, the leading source of health care business intelligence. -- Back to top.
Is prescription drug coverage adequate? There can be big differences among plans in their medication benefits. Check on co-payments, the pharmacies you can use, and the maximum amounts that the plan pays per year. On many plans, you will have much smaller co-payments when you choose lower-cost generic drugs. -- Back to top.
Does the plan offer preventive and other specialized services? Look for plans that cover vaccinations, preventive screenings (such as mammograms), and "well visits" to the doctor. Also check for coverage for dental and eye care. -- Back to top.
How extensive is mental-health coverage? Services by a psychologist or psychiatrist may be limited in the number of office visits and/or the amount of reimbursement per session. There may also be caps on the number of inpatient hospital days for covered psychiatric disorders and substance abuse. -- Back to top.
Are "complementary" or "alternative" services part of the plan? Check whether the plan pays for treatment by chiropractors or acupuncturists, for example. -- Back to top.
Does the plan have a "lifetime maximum"? There may be a limit to the total health care benefits available to you over a lifetime—typically, $1 million. This may seem like a lot of money, but if you develop a catastrophic illness or have a major operation (an organ transplant, for example), you could be well on your way to reaching the maximum level. For that reason, the higher the cap, the better. -- Back to top.
What do your co-workers think of their plan? If you get your health coverage at work, ask your fellow employees whether they're satisfied with the plans offered by your employer. If you are new to the company or the community, co-workers are also a good referral source for choosing a physician and hospital provider. -- Back to top.