Go Ahead--Pick a Plan, Any Plan

Each autumn, packets loaded with spiffy health plan brochures and book-length lists of doctors and hospitals arrive at our homes or in our office mailboxes.

Officially, it’s known as open enrollment--the once-yearly period in which people with employer-provided medical insurance can change health plans. (People 65 or older who are eligible for Medicare can change their medical benefit elections throughout the year.)

Open enrollment means open season for medical consumers as health insurers aim to entice us to remain with, or switch to, their plan.

The vast majority of people offered a choice of health plans will stay put with their current program. But that won’t be an option this year for hundreds of thousands of Californians whose health plans were swallowed up in corporate mergers among some of the state’s biggest HMOs.

Members of health plans that are merging will want to make sure that their favorite physicians offer the new plan.

If you’re thinking about switching health plans, there is much to consider: cost, convenience, benefits, and which doctors and hospitals are available to you. It can be a daunting task.

While many of us won’t spend the hours it can take to do detailed comparisons of plans, there is more help available than you might think.

Over the past few years, some organizations have begun publishing comparative data on hospitals, medical groups and health plans. Such efforts, while still in their infancy, are expected to grow.

Meanwhile, as you ponder your choice of health plans, here are a few questions to consider.

Question: What do I need to know about the different benefits health plans offer?

Answer: Ask your employer or the health plan for a copy of the plan’s summary of benefits. Read it carefully. Questions you might ask include:

* Are there any limits for coverage for preexisting conditions?

* What is the plan’s process for deciding which tests and treatments are covered and which aren’t?

* Are certain services limited or excluded altogether, such as infertility treatments or in vitro fertilization?

* Does the plan offer mental health, vision or dental services and, if so, what are the restrictions on those benefits?

* What about chiropractic and other alternative health services?

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Q: What are some other factors to consider?

A: Health experts recommend that, in comparing plans, you pay special attention to benefits that are most important to you and your family. For example, does the plan allow direct access to obstetrician-gynecologist or pediatricians? Are medical clinics open on evenings or weekends? Are your family’s favorite doctors in the plan?

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Q: What are the differences between HMOs, PPOs, POSs and indemnity plans?

A: There are numerous differences, but they basically come down to your freedom to choose doctors, benefits and costs. HMOs (health maintenance organizations) are the most restrictive plans and limit your choice of doctors and, generally, require you to get approval from a primary doctor before you receive services. HMOs boast that they also pay for more preventive health services than other types of health plans.

A less-restrictive type of HMO is the point-of-service plan, which allows you to see doctors outside the HMO’s approved “network,” although you’ll have to pay deductibles and co-payments when you do so.

The preferred-provider organization (PPO) falls somewhere between an HMO and a traditional indemnity plan. In a PPO, you usually pay a small amount--say, $10 per office visit--if you see a doctor in the approved network. If you go to a doctor outside the network, you’ll pay more. With traditional insurance, you can use virtually any doctor or hospital, but your out-of-pocket costs can be quite high.

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Q: What are some of the considerations when comparing the cost of various health plans?

A: You will want to compare the monthly premiums, deductibles (mostly for non-HMO plans) and co-payments (the amount you must kick in for doctor office visits or prescription drugs). With non-HMO plans, check to see if there is a limit on out-of-pocket costs or a lifetime limit on what the plan will pay for your medical care.

If you have a medical need requiring ongoing treatment, equipment or a prescription drug, for example, make sure it is covered by the plan and in what circumstances.

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Q: Are there any ways to compare the quality of health plans?

A: It’s not easy. Besides talking with friends, doctors or your employee benefits department about the reputation of certain plans, there is a dearth of reliable information.

Find out if the health plan is accredited by the National Committee for Quality Assurance by checking out that organization’s Web site at https://www.ncqa.org or call (800) 839-6487 for a free accreditation report by state. Be aware, however, that experts say that accreditation is no guarantee of a health plan’s excellence.

The California Department of Corporations, which regulates HMOs, also has summaries of its medical surveys of plans. The latest surveys are available by calling (213) 736-3131 or (916) 324-8176. The agency also collects information about HMO complaints.

Traditional insurance plans and PPOs are regulated by the California Department of Insurance, which can be reached at (800) 927-4357. Also, the California Public Employees Retirement System, a big purchaser of health care, has some comparative information about health plans available on its Web site, https://www.calpers.ca.gov.

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Q: If I’m unfamiliar with any of the “primary care doctors” offered in my health plan, how should I choose one?

A: You can start by asking other people at work for recommendations. After you settle on a doctor, you can check physicians’ credentials, such as their history of malpractice lawsuits, with the California Medical Board.

Also, make sure that your primary doctor is accepting new patients from your health plan.

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Q: What are some questions I should ask my primary care physician?

A: Consumer experts suggest:

* Ask the doctor or his or her staff if they are happy with a particular health plan. If the doctor isn’t happy, take note: that frustration may be reflected in how you’re treated.

* Will you get to see the doctor, a nurse or a physician’s assistant for routine office visits?

* What is the procedure for seeing a specialist?

* What is the procedure for getting a second opinion?

* How long does it take to schedule a routine checkup?

* What hospitals does the doctor use and what groups of specialists are patients referred to?

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Q: When I choose a primary physician, I’m generally choosing a medical group. Is there any information to compare medical groups or hospitals?

A: Until recently, it’s been very difficult to get information about the quality of medical groups or hospitals, but some help is coming.

The Pacific Business Group on Health, a San Francisco-based employers’ health care purchasing coalition, recently completed a patient satisfaction and quality survey of more than 50 medical groups--including most of Southern California’s biggest medical groups. Participation in the survey was voluntary for the physician groups. The results are available on the group’s Web site at https://www.healthscope.org. The site also includes some comparative information on hospitals, such as caesarean section rates.

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Q: My health plan says that its doctors are “credentialed.” That sounds good, but what does it mean?

A: The credentialing process basically weeds out the obviously bad doctors: those without medical licenses, who have had their hospital privileges revoked or who have had drug-related problems. What it doesn’t tell you is whether the doctors are clinically competent. Some plans also “re-credential” doctors every few years to see if patients are registering complaints, or if the doctor is using too few or too many medical services. It’s important that the plan follow up on the re-credentialing process by booting out bad doctors.

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Q: What do I need to know about emergency room treatment?

A: If you or a family member has a medical condition that might result in a trip to the emergency room--asthma or a heart condition, for example--check out the plan’s emergency procedures. Do you need prior authorization for emergency treatment? What is the plan’s definition of an “emergency”? Will the plan pay for emergency treatment if you and the insurer disagree on what constituted an actual emergency?

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Q: What are some things to consider if I or someone in my family has a chronic illness that requires specialist care?

A: Some consumer and patient advocacy groups caution that HMOs, with their policies limiting access to specialists, may not be good choices for people with chronic conditions. They say sicker patients tend to be happier in plans that offer wider choice of specialists and freer access to them--such as PPO or POS plans--because there is less of a “hassle factor.” But there is some research to suggest that HMOs can provide care as good or better than other types of insurance for people with certain chronic illnesses.

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Q: I’ve heard that some health plans place restrictions on prescription drugs. What’s that all about?

A: Many health plans use “formularies,” which are limited lists of brand-name or generic drugs that are “recommended” to doctors and pharmacists. In the past year, some plans have dropped many higher-cost drugs from their approved lists to cut their costs. Health experts suggest that you ask the health plan for a copy of their formulary list and check whether the drugs you use regularly are on the list. Also inquire whether you’ll have to pay more for brand-name drugs, what your co-payments, if any, will be, and what pharmacies are included in the plan.

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Q: If I have a complaint with my health insurer, what rights do I have as a member to appeal decisions?

A: Most people won’t give a thought to how disputes are resolved by their health plan until they encounter a serious problem. But it merits some consideration before you sign up. For example, many people are unaware that some health plans require them to resolve legal disputes through private arbitration instead of by going to court. Experts recommend that you review a health plan’s procedures for handling member complaints and appeals.

HMO members who are unable to resolve their disputes with the their plan can file complaints with the state Department of Corporations at (800) 400-0815.

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Sources: American Assn. of Retired Persons; Center for the Study of Services; Consumers Union; Families USA Foundation; Health Pages; Pacific Business Group on Health; “The HMO Health Care Companion” (HarperPerennial, 1994) by Alan G. Raymond.