Date Published: 16 October 2008
AMA offers ten topics to consider before choosing the family's health plan
It’s October, and American workers are being bombarded with messages from health insurance companies that want to get their attention during the “open enrollment” period. During this time, most employers allow workers to change health insurance plans offered by the company, add or drop family members’ coverage. To help ensure that employees make the best choices in health care coverage for their families, the American Medical Association (AMA) offers a series of questions employees can use to get information they need from health insurers.
Now more than ever, having all the best information on a health plan is important. More than 177 million American workers and their families are enrolled in some form of employer-based health insurance. Premiums health insurers charge are on the rise again, and the vast majority of workers are being called upon to shoulder significantly more of the premium costs. The average contribution workers pay for family coverage has recently risen to $3,354, according to Kaiser Family Foundation. In addition to their premium contributions, most covered workers face additional payments when they use health care services.
“We want to make sure that workers choose a plan that is right for them and their families in terms of both cost and coverage. Whether they choose a traditional fee-for-service plan, a health savings account, a PPO or HMO, it’s important that Americans know exactly what protection and benefits they’re due from insurance providers when they enroll,” said AMA President-elect J. James Rohack, M.D.
AMA’s Ten Topics to Consider Before Choosing a Health Plan
1. Are your family’s doctors in the plan? If not, what will you have
to pay out-of- pocket for office visits or other services your doctor prescribes?
Is the plan’s directory of participating physicians up-to-date and accurate?
Are there physicians on the list who are still accepting new patients?
2. What does the plan cover? Some plans may be a much better fit than others for your health care needs. Young families may want prenatal and well-child visits. Older couples may want to know if rehabilitation and home health care are covered. Does the plan include prescription drugs, preventive care, mental health services and second opinions? If it covers prescription drugs, how much will you have to pay out of pocket for the drugs your family needs? Are there limitations on routine care or hospital stays? Will you be able to use labs and other facilities that are convenient to where you live or work? How much of the money spent on premiums actually pays for medical care, rather than profits, marketing, CEO salaries and other administrative costs?
3. How does the plan treat pre-existing conditions? Does it publish or provide patients with guidelines used to determine coverage? Patients with pre-existing conditions, such as cancer, will want to know what hospitals and treatments they can expect if their disease recurs.
4. Does your primary care physician have to receive permission from the insurance company to refer you to a specialist? Does that rule include gynecologists, or specialists you see regularly for a chronic condition? Does the insurer use penalties or incentives to induce physicians in the plan to limit referrals in anyway?
5. Does your physician’s contract with the insurance company prevent him or her from telling you about certain options or procedures? Will your physician need to receive authorization from any other source before discussing treatment? Does the plan require pre-authorization for diagnostic testing, hospitalization or other patient care needs?
6. How does the plan determine which treatments are “experimental” or “investigational?” What standards are used? Does it base decisions on objective guidelines developed by the National Institutes of Health, national medical specialty societies and other medical groups?
7. Will the plan pay for emergency care when the patient is out of town, away from a network provider? What are the limitations for coverage of emergency services?
8. How does the plan treat its physicians? Can doctors be removed from a plan without cause or due process rights? Can the insurance plan change its contracts with physicians without advance notice or consultation? How stable is the physician panel? Will the doctor you see this year still be a part of the plan next year?
9. How does the plan cover treatments for “congenital conditions” and “cosmetic” conditions? How does the plan define cosmetic conditions? Will it deny coverage for breast reconstruction, cleft palate or limb salvage as “cosmetic” procedures? Will it deny coverage for all or any treatments due to congenital conditions or illnesses?
10. How does the plan define “medically necessary"? Does it only cover treatments determined by the plan to be “reasonably reimbursable” while avoiding payments for expensive treatment options, even if current guidelines indicate the treatment is medically necessary? Does the plan have a well defined appeals process that patients can use when a service is denied?
Source: American Medical Association (AMA).