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Health Insurance - Choosing a Health Plan
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:
Your Health Plan Affects Many Things
What Are Your Choices?
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. How to Make Decisions Based on Quality Please enter the name of each plan you want to compare on a separate line (Plan A, B, and C). Plan A: ________________________________ Read the questions. Which are most important to you in choosing a health plan?
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. Rate Your Health Plan Choices Plan A: [_] 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 (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:
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/state_web_map.htm. Does the plan provide preventive services to help keep people well? Plan A: [_] Yes Does it do a good job of helping them get better when they are sick? Plan A: [_] 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? Is the plan accredited? Plan A: [_] 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.
Does the plan have the doctors and hospitals I want or need? Plan A: [_] Yes 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. 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. Does the plan provide the benefits I need? Plan A: [_] 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. Are These Services Covered? 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 Other:___________________ Other:___________________ Other:___________________
Do the doctors, pharmacies, and other services in the plan have convenient times and locations? Plan A: [_] Yes Here are some questions you may want to call the plan to find out:
Does the plan meet my budget? Plan A: [_] 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. Cost of Plans 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? If there is a deductible, how much will I have to pay before the
plan starts to pay for prescription medicines? How much will I have to pay (co-payment) each time I use a service? 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?
Health Insurance -
Choices Programs & Coverage Types For Quality Health Care
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