The first step in selecting a health insurance plan is determining
your priorities and needs. The next step is comparing
those priorities and needs with the coverage that a given
health insurance plan offers. To make the selection process
manageable, the next sections explain some of the major features
that make up a health insurance plan.
Covering yourself, your spouse,
and your dependents
If you’re employed and married or have a domestic partner,
you may have some flexibility in choosing secondary coverage
under a spouse’s or partner’s plan. For example, two adults
who each have individual coverage may pay less in premiums
than if both are covered under one policy with a family plan.
If you and your spouse are each covered by a group plan, you
may be able to get secondary (additional) coverage under the
other’s plan, or you may decide to forego secondary coverage
and stick with one plan per person. Or one spouse may drop
his or her employer’s insurance altogether and obtain coverage
under the other’s policy. (Be sure that neither plan has
provisions that prohibit this choice.) Weigh the cost of each
option against the coverage you get before making a decision.
Some families include unmarried domestic partners. Check
out your plan’s policies regarding coverage for domestic partners,
but don’t be surprised if coverage isn’t available.
The issue of health insurance for domestic partners has no
national legislation, nor does any state have regulations covering
its employees’ domestic partners.
To cover a person under your health insurance plan, that person
must be considered a dependent. The definition of
dependent is based on your plan’s legal requirements concerning
financial support. (In an employer-sponsored plan,
the employer may also have input into the definition of
dependent.) Some plans consider a child a dependent only if
the child meets all of the following very specific criteria:
- The child is your responsibility by birth or legal adoption,
or the child is a stepchild or a foster child.
- The policyholder provides more than 50 percent of
financial support and maintenance for this child.
- The policyholder can claim the child as an exemption
on his or her federal income tax return.
A child is considered a dependent if a legal court order mandates
that the policyholder must provide coverage for the
child. Other individuals may be considered dependents if
they satisfy IRS requirements.
health insurance plans’ regulations regarding coverage for
children and/or other dependents may vary greatly, so check
out the plans carefully. To make administration simple and
consistent, some companies use some variation of the birthday
rule, in which the primary coverage for eligible children
is through the plan of the parent whose birthday falls in the
earlier month of the year. For example, a parent born in May
1954 would assume coverage for the children, even though
the spouse born in September 1950 is older.
Selecting doctors and hospitals
Many health insurance plans have an arrangement between
the insurer and a selected group (or network) of doctors and
hospitals and other health care providers. Such plans offer
significant financial incentives to policyholders to use the
providers in that network, including reducing your benefits
when you use doctors and hospitals outside the network.
Before you decide to buy a particular health insurance plan,
find out which doctors and hospitals are included in the
plan’s network. Use this section to evaluate those doctors and
hospitals. If they don’t satisfy your needs, evaluate other doctors
and hospitals with this section and then look for a plan
that uses the doctors and hospitals of your choice.
Consider the following factors when you assess doctors and
hospitals in relation to a health insurance plan.
Location of doctors and hospitals: If you prefer to deal
with a nearby doctor or hospital, check to see whether
these providers are part of the network of the plan you’re
considering. If you travel much, find out what the plan’s
benefits are if you need to consult doctors or visit hospitals
outside the plan’s provider network.
Doctors are usually associated with a particular hospital.
When selecting a doctor, keep in mind that you usually
end up using the services of the hospital with which that
doctor is affiliated.
Primary care physician (PCP): A primary care physician
is a doctor who provides or authorizes all care for a
patient. Most HMOs and PPOs require their members to choose a primary
care physician.
If freedom of choice in selecting your primary care physician
isn’t that important to you, an HMO or PPO may
be a good choice for you.
If you’re already happy with a doctor who isn’t part of a
plan network, a fee-for-service plan (also known as an
indemnity plan) may be a good choice for you. This type
of plan allows you the greatest choice of doctors and hospitals.
You can also ask your out-of-network provider to
consider joining a network check with your benefits
administrator for the forms.
Some doctors require payment at the time of service.
Others offer a grace period for payment. Still other doctors
file your insurance claim for you or file directly with
the insurer. If you prefer not to pay the doctor and wait
for your insurance company to reimburse you, find out
what the doctor’s policies are and whether you can make
special arrangements for payment.
Specialists: Some plans require that you get a referral
from your primary care physician prior to each time you see a specialist. Getting a referral usually involves a visit
to the primary care physician for diagnosis and perhaps
treatment to see whether the more expensive visit to the
specialist is necessary. Check to see whether your preferred
specialist is in the plan’s network or whether the
network has a specialist who deals with your particular
condition. Using an out-of-network specialist may cost
you more.
Hospitals’ quality of care: Most hospitals participate in
an accreditation program that the Joint Commission on
Accreditation of Healthcare Organizations (JCAHO)
administers. This organization surveys hospitals every
three years to assure that they meet specific quality standards
for staff and equipment, as well as for their success
in treating and curing patients. Make sure that the hospitals
within your plan’s network are accredited.
Call your state department of health, health care council,
or hospital association to find out what kind of consumer
information is available. You may also call or visit
the hospital’s quality assurance staff. They should be able
to tell you how they oversee and work to improve the
hospital’s quality of care. In addition, ask them about
recent patient satisfaction surveys.
Nursing staff: Ask the hospital’s nursing staff how the
staff is structured. In functional nursing, each nurse is
responsible for particular tasks. In primary nursing, each
nurse is responsible for a certain number of patients, generally
resulting in better care. The patient-to-nurse ratio
should not exceed six to one. Check that the hospital in
your plan’s network has a structure and a patient-to-nurse
ratio that provides optimal care.
General or specialty hospital: If you or your dependents
have a condition that requires medical staff with specific
experience, you may prefer to be affiliated with a
specialty hospital, such as a children’s hospital. In that case, check whether the specialty hospital you may need
is within a plan’s network.
Other services: Research some of the services that may
be important to you does the hospital offer community
education programs, pre-admission testing services
to reduce inpatient time, or a referral network with information
about a more specialized facility? Are hospitalaffiliated
acute care centers (extensions of emergency
rooms) located near your home? Is the food edible? Does
the hospital accommodate special diets? Learn about the
visiting hours and whether lodging is available for parents
to stay overnight with their children. Tour the hospital
to find out whether the rooms and halls are clean
and comfortable and the staff is friendly and helpful.
Waiting for coverage to start
Be sure that you know exactly when your coverage begins.
Insurance companies may sometimes impose a waiting period
between the time you apply for or enroll in a plan and the
date your coverage takes effect. The waiting period sometimes
due to a pre-existing condition may apply to some
or all of a plan’s benefits.
If you enroll in a group plan when you begin a new job or
when your employer offers an open enrollment period, you
usually don’t have a waiting period. Individual plans are usually
stricter and most likely will impose a waiting period.
Generally, you don’t begin paying premiums until your waiting
period is over.
Keep in mind the kinds of medical care you may need when
you’re switching insurance companies or plans and be sure
that you remain covered, perhaps by extending your current
plan and overlapping it with a new one.
Understanding accreditation of health
insurance plans
You can check on the quality of the health insurance plan
you’re considering through your state’s department of health
or insurance commission or through consumer publications.
Investigate the insurance company itself by checking your
library for insurance company ratings by organizations such
as The A.M. Best Company, Standard & Poor’s, and
Moody’s. These organizations base their evaluations on the
insurance companies’ financial records, which may give you
an idea of a company’s stability. A highly-rated insurance
company generally won’t go out of business overnight and
disappear without paying your claims.
Also check for accreditation, which indicates that a plan meets
certain national standards set by independent organizations
such as the Joint Commission on Accreditation of Healthcare
Organizations (JCAHO). An insurance company’s decision
not to participate in an accreditation program does not
reflect one way or another on its quality. To find out whether
the plan you’re interested in is accredited, ask your employer’s
benefits manager or call the insurance company itself.
One company that offers accreditation of health insurance
plans is the National Committee for Quality Assurance
(NCQA). This company evaluates a health plan’s organization,
structure, and quality improvement process. NCQA
also uses the Health Plan Employer Data and Information
Set (HEDIS), a group of about 50 factors, to measure plans’
quality of care.
Using Your health insurance Checklist
As you work through the Checklist, keep in mind current medical conditions, as well
as the possibility of accidents, serious illnesses, and other surprises
that life may throw your way. For now, leave blank the
areas that you’re unsure about. By the end of the list, you
should have a clear and fairly comprehensive picture of what
your needs are and what type of health insurance plan will
satisfy those needs. | 
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