Choosing A Health Plan
Contents
Today there are more health plans to choose
from than ever before. Not everyone has a choice. But if you
do, this section can help you choose the plan that offers the
best quality for you and your family.
The quality of health plans varies widely.
In 1997, a study published by the National Committee for
Quality Assurance (NCQA) showed differences in the ways
managed care organizations provide access to care, keep people
healthy, treat illness, deliver high-quality service, and
satisfy patients. For example, studies show that treating
heart attack patients with beta blocker drugs saves lives. The
NCQA found that in some health plans, most heart attack
patients got beta blockers. In other health plans, only one in
three did.
Research shows that Americans say that
quality is the most important thing they think about when
choosing a health plan. But research also shows that few
people understand their options well enough to make an
informed choice.
Quick Check for Quality
Look for a plan that:
●
Has been rated highly by its members on
the things that are important to you.
●
Does a good job of helping people stay
well and get better.
●
Is accredited, if that is important to
you.
●
Has the doctors and hospitals you want or
need.
●
Provides the benefits you need.
●
Provides services where and when you need
them. Meets your budget.
Your Health Plan Affects
Many Things
●
Who will
care for you (doctors and other health care providers), and
how much choice you will have.
●
What kind of
care you will receive (for example, which preventive
services are covered?).
●
Where you
will receive your care (which hospitals, for example).
●
When you
will receive your care (will you receive it when you need
it?).
●
How you will
be cared for (the quality of care you receive).
●
How much you
will pay.
Back to Contents
What Are Your Choices?
The two major types of health plans are
"fee-for-service" and "managed care." Managed care plans can
go by many names, including:
●
Health Maintenance Organization (HMO).
●
Preferred Provider Organization (PPO).
●
Individual Practice Association (IPA).
●
Point of Service (POS) plan.
But different groups do not always define
these names the same way.
Do not be confused by whether the plan is a
"fee-for-service" plan, or whether the plan is one of the many
kinds of managed care plans. What you need to understand is
not the plan's label, but the characteristics of the plan.
Research shows that it is important to understand your options
and how they affect your choice of providers and services,
costs, and quality of care.
Back to Contents
How to Make Decisions
Based on Quality
The next section lists several questions you
may want to consider when choosing a health plan. These
questions are based on research about what consumers want to
know when choosing health plans. Under each question you will
find more information to help you choose the plan that is
right for you. You also will find a way to compare the health
plans you are looking at. Here's how:
Please enter the name of each plan you want
to compare on a separate line (Plan A, B, and C).
Plan A: ________________________________
Plan B: ________________________________
Plan C: ________________________________
Read the questions. Which are most important
to you in choosing a health plan?
●
Do
members rate the plan highly on things that are important to
me?
●
Does
the plan provide preventive services to help keep people
well?
●
Does it do a good job of helping them get better when they
are sick?
●
Is
the plan accredited?
●
Does
the plan have the doctors and hospitals I want or need?
●
Does
the plan provide the benefits I need?
●
Do
the doctors, pharmacies, and other services in the plan have
convenient times and locations?
●
Does
the plan meet my budget?
Read and think about the information under
each question. Then ask yourself the question. If the answer
is "yes" for a plan, check the box next to its name.
Of course, the answers to these questions
may not be as simple as "yes" or "no." Still, these questions
should help you to think about and compare your health plan
choices.
Do this for all the questions you have
chosen.
Back to Contents
Rate Your Health Plan
Choices
Do members rate the
plan highly on things that are important to me?
Plan A: [_] Yes
Plan B: [_] Yes
Plan C: [_] Yes
Before you join a plan, it is hard to know
what kind of care you will get. One way to find out is to
learn what members of the plan say about it. This kind of
information is called consumer ratings or consumer
satisfaction information.
More and more States, businesses, health
plans, Medicare, and even the Federal Government's personnel
office are starting to use a survey called Consumer Assessment of Health Plans -
http://www.ahcpr.gov
(CAHPS®). It tells them what members think of the plans they
are in. CAHPS® was designed by national experts in health care
quality, under a project funded by the Agency for Health Care
Policy and Research.
Also, NCQA has added CAHPS® survey questions
to its own member satisfaction survey. The NCQA survey is part
of its performance measurement program, called HEDIS (Health
Plan Employer Data and Information Set).
The information from the CAHPS® surveys is
summarized in reports to help you compare health plans and
decide which one is best for you. Here are examples of the
kind of information you will find in a report that is based on
CAHPS® survey questions:
●
Do members get the health services they
need? Without long waits?
●
How easy is it for members to get a
doctor they are happy with?
●
How easy is it to see a specialist?
●
Do doctors in the plan listen carefully?
●
Do they explain things well?
●
Are office staffs polite and helpful?
●
Is the health plan's customer service
good at giving information and helping with problems?
●
Do members have too many forms to fill
out?
●
How do members rate the care from the
doctors and other health care providers in the plan? How do
●
they rate their plan overall?
Find out where the survey information came
from. Is it CAHPS®, HEDIS, or another source? Are you
satisfied that it is a reliable source? Who collected the
data?
How can you find consumer ratings? Ask your
employer, Medicare or Medicaid office, or the health plan if a
CAHPS® or HEDIS survey report is available. If not, ask if
there are other consumer ratings.
You also may want to check your phone book
for your State's department of health, or the insurance
commissioner's office. For more help in finding your State
health insurance contact, write or call the National
Association of Insurance Commissioners at Executive
Headquarters, 2301 McGee, Suite 800, Kansas City, MO
64108-2604; telephone 816-842-3600 or, if busy 816-374-7175.
The information also is available at its Web site:
http://www.naic.org.
Back
to Contents Back to Questions
Does the plan provide
preventive services to help keep people well?
Plan A: [_] Yes
Plan B: [_] Yes
Plan C: [_] Yes
Back to Contents Back to Questions
Does it do a good
job of helping them get better when they are sick?
Plan A: [_] Yes
Plan B: [_] Yes
Plan C: [_] Yes
The Health Plan Employer
Data and Information Set (HEDIS) uses various types of
quality measures. The HEDIS clinical performance measures are
based on information such as members' medical records. These
measures help to compare how well plans prevent and treat
illness. For example, one HEDIS measure looks at how many
adult smokers or recent quitters were advised to quit by a
health professional in the plan. Another looks at whether
2-year-olds are up to date on recommended shots. Some other
HEDIS measures look at breast cancer screening, prenatal care,
and at eye exams to prevent blindness in people with diabetes.
States, employers, health plans, and groups
like the California-based Pacific Business Group on Health use
HEDIS performance measures to prepare reports for consumers.
These reports are known as performance reports, report cards,
or various other names. They also may include HEDIS member
satisfaction ratings or other consumer ratings.
To find out if there is performance measure
information available on the plans you are looking at, ask
your employer, Medicare or Medicaid office, or the health
plan. Or, call your State department of health or the
insurance commissioner's office.
When you read the report, check to see where
the measures came from. Are you satisfied that it is a
reliable source?
Back to Contents Back to Questions
Is the plan
accredited?
Plan A: [_] Yes
Plan B: [_] Yes
Plan C: [_] Yes
Many health plans choose to be reviewed and
accredited (given a "seal of approval"). Contact the following
organizations to find out if the plans you are looking at are
accredited, or find out from the plans.
●
The National Committee for Quality
Assurance (NCQA) evaluates and rates managed care plans
using
●
more than 50 standards. The standards focus on efforts
to continuously improve quality of care;
●
doctors'
credentials (training, licensing, and other background
information); members' rights and
●
responsibilities;
preventive health services; and whether appropriate health
care services are provided.
●
Visit
NCQA's Web site at
http://www.ncqa.org to
generate a report card on one of hundreds of health
●
plans.
You can also call 1-888-275-7585 or 1-800-839-6487 to ask
for the following information:
●
Accreditation Status List,
which lists all the health plans NCQA has reviewed. (No
charge)
●
Accreditation Summary Report
for any health plan reviewed since July 1995. ($3 per report
by mail)
●
The Joint Commission on Accreditation of
Healthcare Organizations (JCAHO) evaluates and accredits
●
all
types of health care organizations. JCAHO standards focus on
patient-related areas it views as
●
most closely related to
improving health outcomes. The standards cover: rights,
responsibilities, and
●
ethics; continuity of care; education
and communication; health promotion and disease prevention;
●
leadership; management of personnel and health information;
and continuous quality improvement.
●
Call 630-792-5800 to ask for information on specific
accredited managed care or other organizations.
●
Or visit the JCAHO Web site:
http://www.jcaho.org.
Information on accredited organizations is free of
●
charge.
●
The American Accreditation HealthCare
Commission/Utilization Review Accreditation Commission
●
(URAC)
develops accreditation standards and programs for managed
care. Its Network Standards
●
address five general areas:
network management, utilization management (checking to see
that health
●
care resources are used appropriately), quality
management, credentialing, and member participation
●
and
protection.
●
Call (202) 216-9010 for
information on accredited organizations. Or, for a free list
of accredited
●
organizations, visit the Commission/URAC's Web
site at
http://webapps.urac.org.
Back to Contents
Back to Questions
Does the plan have
the doctors and hospitals I want or need?
Plan A: [_] Yes
Plan B: [_] Yes
Plan C: [_] Yes
Back to Contents Back to Questions
Here are some questions to think about:
Are you happy with your current doctors?
Call their offices to find out which plans
they are in. You may be able to choose a plan that will allow
you to keep seeing those doctors without paying extra.
Back to Contents Back to Questions
Do you want to make sure the plan
includes the kinds of doctors you will want to see?
Call the plans you are looking at to get a
list of their doctors and other providers. Or, ask your
employer's benefits manager.
And remember, the hospital you go to often
depends on the plan you are in and where your doctor has
privileges. If going to a certain hospital is very important
to you, keep that in mind when choosing a plan.
Back to Contents Back to Questions
Does the plan provide
the benefits I need?
Plan A: [_] Yes
Plan B: [_] Yes
Plan C: [_] Yes
Which health care services are most
important to you and your family? Do the plans you are
comparing provide these services? Check the health plan
materials from your employer or the plans. Or, ask your
employer's benefits manager or the plan's customer service
office. For services that are provided by each plan, check the
boxes next to those services that you want or need. There are
extra spaces at the end of the list in which to add other
services.
For a printable Text Version -
click here
|
Are
These Services Covered? |
Plan
A |
Plan
B |
Plan
C |
|
Cancer screening (colorectal cancer tests, mammograms, Pap
smears, etc.) |
[_] |
[_] |
[_] |
|
Cholesterol screening |
[_] |
[_] |
[_] |
|
Immunizations (shots) |
[_] |
[_] |
[_] |
|
Prenatal care |
[_] |
[_] |
[_] |
|
Well-baby care |
[_] |
[_] |
[_] |
|
Care for a pre-existing condition
(one you have before joining the plan) |
[_] |
[_] |
[_] |
|
Diabetes supplies |
[_] |
[_] |
[_] |
|
Dental exams/treatments |
[_] |
[_] |
[_] |
|
Eye
exams/glasses/contact lenses |
[_] |
[_] |
[_] |
|
Hearing exams/hearing aids |
[_] |
[_] |
[_] |
|
Outpatient prescription medicines |
[_] |
[_] |
[_] |
|
Medical equipment for use at home |
[_] |
[_] |
[_] |
|
Mental health services |
[_] |
[_] |
[_] |
|
Physical therapy |
[_] |
[_] |
[_] |
|
Hospice care |
[_] |
[_] |
[_] |
|
Counseling to stop smoking |
[_] |
[_] |
[_] |
|
Drug and alcohol counseling |
[_] |
[_] |
[_] |
|
Alternative treatments (such as acupuncture or
chiropractic services) |
[_] |
[_] |
[_] |
|
Home health care |
[_] |
[_] |
[_] |
|
Adult day care |
[_] |
[_] |
[_] |
|
Nursing home care |
[_] |
[_] |
[_] |
|
___________________________________ |
[_] |
[_] |
[_] |
|
___________________________________ |
[_] |
[_] |
[_] |
|
___________________________________ |
[_] |
[_] |
[_] |
Back to Contents Back to Questions
Do the doctors,
pharmacies, and other services in the plan have convenient
times and locations?
Plan A: [_] Yes
Plan B: [_] Yes
Plan C: [_] Yes
Here are some questions you may want to call
the plan to find out:
Are the services close enough to home or
work?
Are they on convenient routes for public
transportation?
Is parking available?
Are offices open in the evenings and on
weekends?
Back to Contents Back to Questions
Does the plan meet my
budget?
Plan A: [_] Yes
Plan B: [_] Yes
Plan C: [_] Yes
Use the health plan materials from your
employer or the plans to answer these questions and enter the
information on the line provided under each plan.
For a printable Text Version -
click here
|
Cost |
Plan
A |
Plan
B |
Plan
C |
|
How
much will the premium cost me each month? |
_____ |
_____ |
_____ |
|
If
there is a deductible, how much will I have to pay before
the plan starts to pay for medical care?
For prescription medicines? |
_____
_____ |
_____
_____ |
_____
_____ |
|
How
much will I have to pay (co-payment) each time I use a
service?
Doctor visit
Hospital visit
Prescription |
_____
_____
_____ |
_____
_____
_____ |
_____
_____
_____ |
|
How
much more will I need to pay if I go outside the health
plan's network of doctors, hospitals, and other providers
to get services? |
_____ |
_____ |
_____ |
Back to Contents
Back to Questions
Sources of Additional
Information
Choosing and Using a Health Plan
Details health plan choices, benefits,
costs, and suggestions for getting the most from your plan. 29
pages. Free.
Agency for Healthcare Research and Quality
Publications Clearinghouse
P.O. Box 8547
Silver Spring, MD 20907
1-800-358-9295
E-mail:
ahrqpubs@ahrq.gov
Web site:
http://www.ahrq.gov
Medicare Compare
http://www.medicare.gov
is an interactive database with detailed information on
Medicare's health plan options. Medicare offers a variety of
free guides on its Web site,
http://www.medicare.gov. Or
call the Medicare Hotline: 1-800-633-4227
How to Choose a Health Plan and Straight
Talk About Health Plans Free.
American Association of Health Plans.
(202) 778-3200
Web site:
http://www.aahp.org (click "For
Consumers")
Guide to Health Insurance
Covers different kinds of plans and
coverage, changing jobs, and answers frequently asked health
insurance questions. 15 pages. Free.
Health Insurance Association of America
1201 F Street, N.W., Suite 500
Washington, DC 20004-1204
(202) 824-1600
Web site:
http://www.hiaa.org
Putting Patients First
Contains a guide to patients' rights and
responsibilities, lists resources for 170 conditions and
diseases, and has a consumer's checklist for evaluating health
plans. 24 pages. Free.
National Health Council
1730 M St., N.W., Suite 500
Washington, DC 20036-4505
(202) 785-3910
Web site:
http:www.nationalhealthcouncil.org
Choosing Quality: Finding the Health Plan
That's Right For You
Helps consumers evaluate health plans.
Covers what to look for, plan accreditation, report cards, and
ways to evaluate quality. Glossary. 4 pages. Free.
National Committee for Quality Assurance,
Publications Center 1-888-275-7585
Web site:
http://www.ncqa.org
Nine Ways to Get the Most from Your
Managed Health Care Program
Topics include referrals, prescription drug
coverage, getting care when you are seriously ill, legal
rights and protections, and grievances. 40 pages. Free.
American Association of Retired Persons
(AARP)
601 E. St., N.W.
Washington, DC 20049
1-800-424-3410
Web site:
http://www.aarp.org
Pacific Business Group on Health Web Site
Offers helpful information about choosing a
health plan and evaluating HMOs. Includes consumer and
physician ratings of California HMOs.
Web site:
http://www.healthscope.org
Your Guide to Managed Care
A 15-page online guide to choosing health
care coverage. Part of an online series published by Health
Pages.
Web site:
http://www.thehealthpages.com
Families USA
Offers an in-depth resource list and
information clearinghouse on managed care.
Web site:
http://www.familiesusa.org
healthfinder®
Provides a gateway to reliable consumer
health information from the Federal Government and other
organizations.
Web site:
http://www.healthfinder.gov
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