1. What is the first thing I should know about buying health coverage?
   
   Your aim should be to insure yourself and your family against the most serious and financially disastrous losses that can result from an illness or accident. If you are offered health benefits at work, carefully review the plans’ literature to make sure the one you select fits your needs. If you purchase individual coverage, buy a policy that will cover major expenses and pay them to the highest maximum level. Save money on premiums, if necessary, by taking large deductibles and paying smaller costs out-of-pocket.
   
   
2. Can I buy a single health insurance policy that will provide all the benefits I’m likely to need?
   
   No. Although you can select a plan or buy a policy that should cover most medical, hospital, surgical, and pharmaceutical bills, no single policy covers everything. Moreover, you may want to consider additional single-purpose policies like long-term care or disability income insurance. If you are over 65, you may want a Medicare supplement policy to fill in the gaps in Medicare coverage.
   
   
3. I’ve had a serious health condition that appears to be stabilized. Can I buy individual health coverage?
   
   Depending on what your condition is and when it was diagnosed and treated, you can probably buy health coverage. However, the insurer may do one of three things:
   • provide full protection but with a higher premium, as might be the case with a chronic disease, such as diabetes;
   • modify the benefits to increase the deductible;
   • exclude the specific medical problem from coverage, if it is a clearly defined condition, as long as the insurer abides by state and federal laws on exclusions.
   

1. What is an HMO?
   
   An HMO is a Health Maintenance Organization, which is a network of health care providers including doctors, hospitals, pharmacies, and other medical facilities and professionals. The network works together to manage the quality and cost of each member's health care.
   
   
2. How does an HMO work?
   
   Each HMO member selects a Primary Care Physician (PCP) from a directory of participating physicians in the areas of general practice, family practice, internal medicine or pediatrics. The PCP will coordinate all of the member's health care needs. If the PCP can effectively provide care, he will. If he determines a specialist is needed, he will refer the member to a Participating Specialist in the HMO network.
   
   
3. What are the advantages of an HMO?
   
   HMOs are designed to manage the costs of medical care, which means members enjoy lower out-of-pocket expenses compared to traditional Indemnity medical insurance. Visits to the doctor's office, hospital charges and many other medical care expenses are covered at 100% after a small copayment such as $5 or $10 per visit. Generally, prescription drugs, routine physicals, lab tests, vision exams, well-baby care, and maternity visits are covered. HMO plans do not require you to pay an annual deductible before services are covered and usually have no lifetime maximums. HMO providers conveniently take care of most paperwork, so members do not have to complete claim forms.
   
   
4. Are there any drawbacks to an HMO?
   
   Some people who are accustomed to selecting their own health care providers and facilities find working with a Primary Care Physician system to be inconvenient or restrictive at first. However, HMO members who recognize the cost-savings, quality care and conveniences they enjoy with managed care are generally satisfied with the trade-off. No benefits are paid if a member decides to go to a health care provider that is not in the network.
   
   

Questions about POS

1. What is a Point-of-Service Plan (POS)?
   
   A Point-of-Service Plan (POS) delivers health care services using both an HMO network and more traditional Indemnity coverage where individuals can utilize health care services outside the HMO network.
   
   
2. How does a POS work?
   
   At the time medical care is required, members decide to use either an In-Network or Out-Of-Network provider, In-Network managed care benefits are provided as an HMO (small copays, low out-of-pocket expenses and no deductibles, benefit maximums or claim forms). Out-Of-Network benefits are lower, out-of-pocket expenses are higher, and there may be a deductible, benefit maximums, and claim forms to complete.
   
   
3. What are the advantages of a POS?
   
   There is flexibility in choosing health care providers because benefits are paid for both In-Network and Out-Of-Network services. This gives members the opportunity to enjoy the advantages of managed care for most health care needs...and receive benefits for care from providers that are not in the HMO network.
   
   
4. Are there any drawbacks to a POS?
   
   Out-Of-Network benefits can be substantially lower than In-Network benefits and deductibles may apply, so out-of-pocket expenses will be higher.
   
   
   

1. What is a PPO?
   
   A PPO (Preferred Provider Organization) is a network of doctors, hospitals and other health care providers that have been contracted by an insurance company or health plan to provide care at a discount. PPO Plans have two benefit schedules -- one for In-Network and another for Out-Of-Network services.
   
   
2. How does a PPO Plan work?
   
   PPO subscribers are given a PPO directory, which lists participating health care providers. Any provider on the list may be used to take advantage of the PPO benefit schedule and discounted fees. Referrals are not required to visit a specialist. Reduced benefits, similar to traditional Indemnity insurance, are paid for utilization of Out-Of-Network health care providers.
   
   
3. What are the advantages of a PPO Plan?
   
   Because of negotiated discounts, out-of-pocket expenses can be kept reasonable by using PPO providers. There are no deductibles for some PPO benefits. There is flexibility in choosing health care providers because benefits are paid for both In-Network and Out-Of Network services. There is freedom of choice among In-Network providers, including specialists. When In-Network providers are used, out-of-pocket expenses are lower and no claim forms are required.
   
   
4. Are there any drawbacks to a PPO Plan?
   
   The value of a PPO plan depends on the availability of providers, by area, in the network. Claim forms are required for Out-Of-Network benefits.
   
   

Questions about Indemnity Plans

1. What is Indemnity insurance?
   
   Indemnity insurance (sometimes called fee for service) is the traditional method whereby a health care provider is paid directly by the insured person for services. The insured person completes a claim form, submits it to the insurance company, and is reimbursed by the insurance company.
   
   
2. How does an Indemnity Plan Work?
   
   Insureds can select any health care provider they wish. They receive benefits based on their company's benefit schedule, after submitting a claim form.
   
   
3. What are the advantages of an Indemnity Plan?
   
   Indemnity Insurance gives the insured complete free choice of provider, the ability to change providers at any time and the ability to go to a specialist without first having to have the approval of a primary care physician, as is required by HMOs.
   
   
4. Are there any drawbacks to Indemnity Insurance?
   
   Because Indemnity Insurance offers the greatest flexibility and choice and no central cost management, it may have higher out-of-pocket expenses and premium rates. Annual deductibles apply and claim forms are required for services.



Compare Rates on Indemnity Plans

1. I have a physician—is he/she affiliated with this plan? What do I do if he/she leaves the plan?
   
   Discuss with your physician which health plans he/she is affiliated with. Review the list of participating physicians provided by health plans. Check member handbook for information on health plan procedure for visits to out-of-network physicians.
   
   
2. I don’t have a primary-care physician now, or wouldn’t mind changing—how will I choose one, and which physicians may I choose from?
   
   Ask for recommendations from friends and coworkers, including specific reasons why they suggest a particular health plan or a particular physician. Review the health plans’ participating physician panels, including physicians’ qualifications and locations. Check if your preferred physician is accepting patients, and if possible visit his/her office. If a visit is not possible, contact the office to determine office hours and convenience of location.
   
   
3. How does the plan select physicians?
   
   Physicians are selected based on criteria, credentials, and quality monitoring. In addition, affiliation with local hospitals will be important.
   
   
4. How easily can I change primary-care physicians?
   
   Since the patient and primary-care physician relationship is a crucial component of health care, the process should be straightforward and easily understandable. Ask the health plan representative how to go about changing physicians. Generally, you are simply required to notify the health plan and the new physician you are interested in of your desire to change.
   
   
5. How will specialized care be arranged?
   
   If you currently have a relationship with a specialist and wish to maintain it, ask whether he/she is affiliated with plans you’re considering. Talk with health plan member services representatives to determine if the plan will ever cover visits to out-of-network specialists. Also ask your primary care provider which specialists he/she routinely recommends.
   
   
6. Can I use a specialist as my primary care physician?
   
   The choices of primary care providers that are available to you are specified in the member handbook. Contact the health plan’s member services department to discuss your specific needs. Also discuss specialist referrals, and under which services and conditions specialists are utilized.
   

1. My current health is excellent. I have no problems that I’m aware of. Why should I select a primary care or personal physician now?
   
   The relationship between physician and patient is very important; establishing a positive relationship while you are healthy will allow your physician to become familiar with your health history and will make the receipt of care when you are ill easier and more comfortable. Some health plans recommend a baseline physical for new members. Check with the health plan member services department to see how this is arranged.
   
   
2. I have a preexisting condition–will the plan cover it?
   
   A newly passed federal law, The Health Insurance Portability and Accountability Act of 1996 (HIPAA) made dramatic changes to the health insurance laws in an effort to improve access to health insurance. It guarantees the availability and renewability of health insurance coverage for certain employees as well as individuals who purchase insurance on their own. It ensures that most people who are moving from one job to another or from employment to unemployment are not denied health insurance because they have a preexisting medical condition. For information on how the new law applies to your particular situation, contact your employer or health plan representative.
   
   
3. I’m taking a specific medication–will the plan pay for it?
   
   Call the health plan or your personal physician to determine whether the drug is included in the formulary (list of covered drugs). If not, find out what equivalent drug your primary care or personal physician recommends, if needed.
   
   
4. What if a course of specialized treatment is recommended for me by my physician–will the plan approve it?
   
   Your primary care or personal physician will discuss all necessary treatments or health services with you. If a treatment is considered experimental or investigational (of unproven effectiveness), the health plan may use various approaches to determine if these services are covered benefits and available to you. In addition to reviewing the member handbook, contact your employer or health plan member services representative regarding these types of therapies.
   
   
5. I have an ongoing or chronic condition–how will the plan treat it?
   
   Some plans offer special programs for members with chronic conditions such as asthma, cancer, diabetes, AIDS, mental illness, or substance abuse. Check with your personal physician or health plan to determine how plans arrange for continuity of care if you change health plans/physicians while undergoing treatment.
   
   
6. If my goal is to improve my health by: increasing exercise to stay fit; losing weight; stopping smoking, will the plan help me do that?
   
   Health plans offer their members various programs designed to improve health and prevent disease. Talk with your primary care or personal physician or health plan representative to determine which programs are available and would be of benefit to you.

1. What benefits are covered, and what are the limits of coverage?
   
   Review the health plans’ summary of benefits, especially your particular coverage statement. Also, check with employee benefits managers, your state Medicaid agency, and your regional Medicare office.
   
   
2. What types of preventive care, such as immunizations and health screenings, are covered?
   
   Review the health plan summary of benefits. Ask your primary care or personal physician which available health promotion programs are important for your personal health care needs.
   
   
3. What about therapies like acupuncture or chiropractic services?
   
   Review the health plans’ benefits summary chart to determine how coverage decisions are made and whether they offer "alternative therapies" as covered benefits within their network or as out-of-network benefits which may be offered at additional cost.
   
   
4. Are experimental or investigational treatments covered?
   
   Review the summary of benefits for information on coverage of investigational therapies. Some health plans will offer their members access to such treatments through approved clinical trials—research studies which provide patients with new therapies and monitor their progress. Check the health plan policy for coverage. Discuss the benefit of these therapies with your personal physician.
   
   
5. How will I know which prescription drugs are covered?
   
   Discuss your pharmaceutical needs with your personal physician and ask which of these prescriptions are available on the formulary. If in doubt about whether a drug you regularly take is covered, contact the heath plan.

1. What kind of accreditation (voluntary third-party review of a health plan’s policies and procedures) has the health plan received?
   
   Ask if the plan has been reviewed by the National Committee for Quality Assurance (NCQA), The American Accreditation Healthcare Commission/URAC, Joint Commission on Accreditation of Healthcare Organizations (JCAHO) or other recognized accreditation organization; determine status of accreditation and date of reaccreditation. Ask your employer or health plan representative if you desire additional information on accreditation standards or protocols. Most accrediting organizations make information on accreditation decisions available over the internet or through their offices. Contact information for the three main accrediting organizations has been provided at the end of this checklist.
   
   
2. How do I know my plan provides high quality care?
   
   In addition to reviewing report cards (compilations of data on health plan performance and care delivery) and accreditation information, review health plans’ literature regarding the use of ‘best practices’ (successful models of care for certain medical conditions or treatments) and similar initiatives.
   
   
3. How many complaints were filed against the plan or physician in the last year, and how many were upheld?
   
   Ask the health plan (for specific information on the health plan or physician), state insurance department (for health plan), or state medical licensing board (for physician).
   
   
4. How do consumers rate the health plan in independent surveys by businesses or consumer groups?
   
   Check with your employer, state insurance department, state Medicaid agency, or regional Medicare office. Also, check your local library or computer online service. Some health plans also voluntarily publish their own surveys/performance information.

1. What do I have to do to see a specific institutional provider (e.g., hospital, laboratory)? What kind of approval is required before a primary-care physician can refer a patient to a specific provider?
   
   The names of available institutional providers will be specified in the health plan member handbook. Check with your personal physician about which hospitals, laboratories, and other providers he/she routinely utilizes or recommends.
   
   
2. Do I have the option of going outside the plan for specialized care?
   
   Review the health plans’ summary of benefits for terms regarding out-of-network options. Check if the plan contracts with centers of excellence (specialized treatment centers known for their skill in treating particular conditions/diseases), and under which circumstances these centers are used. Many health plans offer point-of-service (POS) options which allow members to receive care out of the health plan network, although at a higher cost. Your primary care or personal physician can help you determine if out-of-network options are appropriate.
   
   
3. What do I do if I have an emergency and want to go to the emergency room?
   
   It is important to understand the process for getting care in an emergency situation; do not wait for an emergency to occur before you learn this procedure. Sometimes you will be able to receive the care you need at an urgent care facility without having to go to the emergency room (see next question). Occasionally, health plans will require that you contact them or your primary care or personal physician before going to the emergency room or within a specified amount of time after you leave.
   
   
4. What do I do if I need urgent care at night/on weekends?
   
   As with emergency care, it is important to review information on where/how to receive after hours care early so that you are prepared should an urgent situation arise. Many health plans make 24-hour urgent care facilities or hotlines available for members who require care on a time-sensitive basis but who are not experiencing a life-threatening emergency.
   
   
5. What do I do if I need care while traveling?
   
   Health plans generally require that you contact them before seeking care outside of their network of providers or within a specified period of time after an emergency has occurred. If you are planning extensive travel, notify your personal physician or health plan in advance to discuss how to obtain necessary medical care while away.
   
   
6. What do I do if my child needs care while away from home (e.g., while at college, traveling, etc.)?
   
   Many health plans offer special provisions for dependent children who are away at school.
   
   
7. How far will I have to travel for routine care?
   
   Review the health plan provider directory for the location of various care facilities including physicians’ offices, hospitals, and urgent care facilities. Ask your primary care or personal physician about office hours and convenience of location.
   
   
8. How easily can I get help over the phone?
   
   Many health plans provide their members with access to 24-hour customer service representatives, advice nurses, or other telephone services. Call the health plan member services line with a sample question to evaluate responsiveness.
   
   
9. What happens if a treatment is recommended and the health plan refuses to authorize it or if I have a complaint about the service I receive from my physician or health plan?
   
   Review the appeals and grievance procedures with member service representatives and ask how the plan handles complaints. Complaints are generally handled internally, although some states require that the health plan offer external grievance resolution. Member services will be able to tell you what options are available to you.
   
   
10. What percentage of members leave the plan each year?
    
    Ask the health plan about their disenrollment rates, check surveys, check with your state insurance department–bearing in mind that there may be many reasons for disenrolling that are unrelated to service, including change of employer or geographic location.

1. What will my monthly premium be?
   
   If you are receiving care through your employer, check with him/her. Premiums depend upon the benefits and services which are available to you through your benefits package, which is usually determined by your employer. Sometimes employers cover the full cost of the premium and sometimes employees share the cost. If you are receiving care under the Medicare program or are receiving private, individual coverage, check with the health plan.
   
   
2. Who is covered by my health plan?
   
   Note whether premium is for individual or family membership and how the health plan defines "family."
   
   
3. What out-of-pocket costs should I expect to pay?
   
   Review summary of benefits information regarding payments for physician visits, emergency room use, mental health coverage, and other services. Also, review the health plans’ policy for covering "out-of-network" or "out-of-plan" services (those provided by a health care provider or institution which is not a part of your health plan’s health care delivery system). Use of out-of-network or out-of-plan services may involve additional out-of-pocket costs. Clarify with your health plan before using these services.