(The Web version of this article is an expanded version of what appeared in newspapers.)

Madison, WI--Many employers who offer employees a choice of health insurance plans allow the employees to change plans during the fall. Even if you are satisfied with the plan you have now, it's a good idea to review all of your available options to make sure your current plan will continue to meet your family's health care needs. You may decide to change plans because your family's needs have changed or because the benefits in your current plan have changed.

The first step in choosing a plan is to think about your family's health care needs. Does anyone have a chronic health condition or other special health care need? If so, is it important to be able to continue your care with your current doctors? Are there any children attending school away from home? Is the cost of the health plan the most important consideration for your family?

Next, gather as much information as you can about your options. If you have employer-sponsored health insurance, your employer will provide you with summaries of each plan. The summaries should explain what services are covered, the limitations on that coverage, and the costs of the plans. You may also want to obtain information from other sources. For example, you can contact the health plan directly or contact business or consumer groups for information. You may ask other employees or friends who have the same coverage about their experiences with the plan. Be sure to ask for the specific reasons for their opinions. Everyone's health care needs are different. Just because a friend or coworker is satisfied (or unsatisfied) with a health plan doesn't mean that you would have the same experience.

You can also contact the Office of the Commissioner of Insurance (OCI) for information. If you are considering purchasing an individual policy, we can verify that the insurance company is licensed in Wisconsin and provide information on the financial strength of the company. Also, a list of companies that received more than the average number of complaints in the last year is available by calling the OCI or checking the agency's Web site. Although a complaint is just that, and is not proof that the insurer did anything wrong, it may be one of the things you consider as you make your decision.

With this information, you will be able to compare the plans and decide which plan best meets your needs. Some things to consider are the plan benefits, type of health plan, costs, and the quality of care.

Plan benefits

When reviewing the plan summaries, read both the list of covered benefits and the list of exclusions and limitations. Check to see how the plans cover any services that you can anticipate your family needing. For example, if you are considering starting a family, you may want to review the plan's benefits for maternity and newborn care.

Most comprehensive health plans will provide some coverage for basic services such as hospitalizations, surgeries, and outpatient treatment for sicknesses. Check to see how the plan covers other services:

• Care for chronic conditions--Some plans offer special disease management programs for serious or chronic conditions such as heart disease, cancer or diabetes. If you have an ongoing health condition, check to see how it will be covered and if the plan offers any special programs that will help you manage your condition.
• Preventive Care--Check to see if physical examinations, health screening tests, and other preventive care is covered, and whether there are any limits to the coverage.
• Prescription drug coverage--If you are taking a prescription medication for an ongoing condition, check to see if it will be covered under the plan.
• Vision and dental care--Check to see if there is any coverage for routine eye exams, eye glasses, or for any dental treatment. Coverage for this type of treatment is often very limited or is totally excluded.

No health plan will cover all of your medical expenses. Reviewing the list of benefits and exclusions in the plan summaries will help you decide which plan will provide coverage for the services that are most important to you.

Type of Health Plan

Check to see if the plans you are considering restrict your ability to choose any physician or other health care providers. Generally, HMO plans are the most restrictive; they only provide coverage if you use the services of participating providers. A traditional fee-for-service plan is the least restrictive and will allow you to choose your own doctors. Preferred provider plans and point-of-service plans allow you to choose any provider, but will pay a larger portion of the charges when you use a participating provider.

As you decide which type of plan is best for you, consider each plan's procedures for receiving services from physicians and other health care providers:

• Restrictions on provider choice--If you are considering enrolling in an HMO, find out if your current doctors participate in the plan. Ask yourself how important it is to you to choose your own doctor if you need treatment.
• Primary care physician--Check to see if the plan requires you to choose a primary care physician to help you manage your care. If so, find out when you will need to get a referral from your primary care doctor and when you need prior approval from the health plan in order to receive coverage for services from other providers.
• Specialty care--If you are currently seeing a specialist, ask if you can continue to see the specialist after enrolling in the plan. Even if the specialist is a participating provider in the plan, you may not be able to continue to see that doctor if your primary care physician practices in a different clinic or medical group.
• Convenience--Check the locations of the clinics and hospitals that participate in the plan. Also check the hours that the clinics are open and find out how to get care after hours. If you are getting your coverage through your employer, pay special attention to the location of the providers if you commute a long distance to work. You may discover that the HMO or preferred provider plan only has providers located near your workplace. This could cause a problem for other members of your family.
• Care when out-of-area--Check to see if the plan provides any coverage if you need care when travelling out of the service area or if you have a child attending school away from home. Although most plans will cover emergency services anywhere, there may be limitations on follow-up services and on routine care.

As you consider which plan is best for your family, remember that there are trade-offs for each type of plan. Although HMOs restrict your choice of a provider to those participating in the plan, there is generally less paperwork involved because the providers will file claims for you. HMOs may also provide additional benefits or offer coverage at a lower cost. Traditional plans may cost more, but they allow you to choose any provider for your care.

Costs

For most people, the cost of the plan is an important factor in choosing a health plan. When comparing costs, consider the total costs you may be responsible for under each plan.

Some potential costs to consider are:

• Premium--Check the amount of the premium you will need to pay for the coverage and the additional amount you will need to pay for coverage of family members.
• Deductible--The deductible is the amount you pay for covered services before the health plan begins paying its share of covered expenses. Some plans have one deductible amount that you pay each year before the plan pays anything. Other plans may have different deductibles for different types of services. For example, a preferred provider plan may have one deductible that applies to services from preferred providers and a separate deductible that applies when you see a non-preferred provider.
• Coinsurance and copayments--You may be required to pay a specific dollar amount or a percentage of the charges for every service you receive. The amount may vary depending on the type of service or health care provider.
• Out-of-pocket limit--Some plans may have a limit on the amount you will be required to pay each year. After you pay this out-of-pocket limit, the health plan will pay all, or will pay a larger portion, of the charges for covered services. Check to see if the plan has an out-of-pocket limit, and how the plan calculates the limit. For example, some plans do not include any copayment amounts in its determination.
• Non-covered expenses--No health plan covers all medical expenses. If the plan excludes or limits coverage for treatment you may need, you will have to pay for the entire bill.

Remember that the plan with the lowest premium may not be the least expensive plan for you. If the plan requires you to pay large deductibles or coinsurance amounts, or if it provides no coverage for treatment you need, you may find that it is more expensive than a more comprehensive plan.

Quality of Care

If you are considering an HMO plan or a preferred provider plan, which limit your choice of providers, you might want to ask the plan how it ensures that you will be able to get good medical care. It is important to understand that quality in medical treatment is difficult to measure because there is no one right treatment plan for everyone. However, there are some things you can review to determine how the health plans you are considering monitor the quality of the care for their insured members.

• Member complaints and appeals--If the information you have received does not explain how the plan resolves complaints and written grievances, call the plan and ask. The plan's representative should be able to explain its procedures and tell you how long it generally takes to resolve problems.
• Provider credentialing--Ask the plan how it selects physicians and other health care providers to participate in the plan. Has the plan established minimum professional requirements for its participating providers, and does it have a procedure to ensure that those requirements are met.
• Report cards--Some health plans, employers, and independent organizations produce "report cards." These reports may include a consumer satisfaction survey. They may also provide information on how well the plan is succeeding in providing specific treatment to its members. For example, one of the measures may show the number of diabetics covered by the plan who have had an eye exam. Although these report cards do not provide a complete view of how the health plan works, they may provide you with important information as you make your decision.
• Accreditation--There are independent organizations that review the policies and procedures of HMOs and preferred provider organizations (PPO), and accredit those that meet the organization's standards. Although this is a voluntary program that some health plans may choose not to undergo because of the associated costs, accreditation is one indication that a health plan has procedures in place to monitor quality of care.

Remember that there is no plan that is best for everyone. No plan covers all medical expenses. However, if you take the time to think about your individual needs and to consider the benefits and limitations of each available plan, you will be able to choose the plan that will provide you and your family the best coverage.

By Barbara Belling
Managed Care Specialist
Office of the Commissioner of Insurance