Selecting the Appropriate Healthcare Insurance Plan

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by Bill Dupes

Choosing the health insurance plan that's right for you is critical to determining the level of the quality of the healthcare you can expect to receive. But let's face it – for many of us, choosing a health insurance plan can be difficult and confusing. When making this vital choice, it's important that we do so with our primary needs in mind (timely access to care, effective treatment and appropriate preventive care) and an understanding of basic factors to consider.

Before you take the step to review health plans, ask yourself the following questions. The answers may have significant bearing on the direction you take.

• What is your budget for a healthcare plan? How much do you think you can afford to spend each month?
• Who will the benefits cover? Adding people to an insurance policy can cause the rates to go up. The more people on the insurance plan, the greater the financial risk to the insurance company, so the rates will increase.
• How often do you go to the doctor? Various medical plans cover routine doctor's office visits with unlimited use but they're more expensive than those with a set number of visits. If you rarely see the doctor, a plan that includes this type of unlimited benefit would be a waste of money. Some health insurance plans include routine wellness visits at little or no cost to you.
• What medical conditions are considered pre-existing conditions in the health plan? Most traditional health plans have strict guidelines for covering pre-existing medical conditions. However, many discount plans and guaranteed acceptance discount programs have no waiting periods or pre-existing condition exclusions. Deciding which option is best for you depends largely on what the condition is and how urgently and frequently you anticipate you will need treatment.
• Do you need dental coverage? If you need major dental work right away, dental discount plans may be your best choice, as they have no waiting periods or limits. Some discount plans offer great savings with much lower rates than traditional insurance plans. Your yearly dental benefit may also be capped at a certain amount. This means that if you need more dental work than is covered, you will pay the excess amount directly out-of-pocket.
• Are you employed or selfemployed? If you work for a large company, your needs and considerations will obviously be different from those of self-employed people.

Door Number 1 or Door Number 2?
There are basically two types of health insurance plans: the preferred provider organization (PPO) and the health maintenance organization (HMO). With the PPO, you can choose from a wide range of doctors, but the cost is proportionately higher. The HMO limits you to care from one group of physicians, but it costs less, with a fixed monthly premium and relatively low co-payments.

HMOs can be good for healthy families who use routine care, such as physicals and vaccinations, and who aren't likely to need out-of-network doctors. If you have children or you see your doctor regularly for a chronic condition, you pay a small co-pay each time you visit.

Doctor, Doctor
Your primary healthcare providers (physician, orthotist/prosthetist, pediatrician, etc.) are obviously a major consideration. People often choose a health insurance plan based on the physicians they want to see under that plan. For other people, specialists may be their chief concern. They choose the insurance that covers the specialists they want and then select a primary healthcare provider who is covered by the same plan.

Location, Location, Location
Another factor to consider is where you'd like to receive hospital care. Is the hospital located within a convenient distance from your home? Does the plan cover healthcare at the hospital where your physician is located?

Some employers also offer another option: a flexible point-of-service (POS) plan. But remember this simple rule of thumb: The more choices you have, the higher the cost. And if you choose to go to a hospital that is out of the health plan's network, the co-payment can be extremely high.

Ultimately, when choosing the health insurance plan that's best for you, the ideal option is to find one that contracts with a large group of qualified primary healthcare providers as well as specialists. This will give you the opportunity to select from many excellent doctors so that you and your family will get the quality healthcare you need and deserve.

National Committee for Quality Assurance
The National Committee for Quality Assurance (NCQA) is a nonprofit organization dedicated to improving the quality of our nation's healthcare system. Since 1990, NCQA has been a central figure in elevating the issue of healthcare quality to the top of the national agenda, driving improvement throughout the healthcare system.

NCQA's contribution to the healthcare system is regularly measured in the form of statistics that track the quality of care delivered by the nation's health plans. These numbers have steadily improved over the past five years: healthcare protocols have been refined, doctors have learned new ways to practice, and patients have become more fully engaged in their healthcare. These improvements in quality care translate into lives saved, illnesses avoided and costs reduced.

The NCQA Web site features a Health Plan Report Card, an interactive tool designed to help you find the health plan that's right for you.

NCQA's Health Plan Report Card can help you answer questions about health plans that would be difficult or impossible to answer on your own – Does this health plan provide good customer service? Will I have access to care I need? Does the plan check doctors' qualifications? If I get sick, which plan will take better care of me?

NCQA accreditation is used by most of the nation's Fortune 500 employers, federal and state governments, and consumers like you to help select among competing health plans. Only NCQA's Health Plan Report Card is based on a rigorous evaluation of clinical quality, member satisfaction and a comprehensive assessment of key systems and processes.

NCQA's Health Plan Report Card has results on hundreds of health plans that care for commercially insured individuals and Medicare and Medicaid beneficiaries. You can create a customized Report Card that shows results for the health plan or plans you want to know about.

© Copyrighted by the Amputee Coalition. Local reproduction for use by Amputee Coalition constituents is permitted as long as this copyright information is included. Organizations or individuals wishing to reprint this article in other publications, including other World Wide Web sites must contact the Amputee Coalition for permission to do so.