What Plan Benefits Are Offered?

What Plan Benefits Are Offered?

Most plans provide basic medical coverage, but the details are what counts. The best plan for someone else may not be the best plan for you. For each plan you are considering, find out how it handles:

  • Physical exams and health screenings.
  • Care by specialists.
  • Hospitalization and emergency care.
  • Prescription drugs.
  • Vision care.
  • Dental services.

Also ask about:

  • Care and counseling for mental health.
  • Services for drug and alcohol abuse.
  • Obstetrical-gynecological care and family planning services.
  • Ongoing care for chronic (long-term) diseases, conditions, or disabilities.
  • Physical therapy and other rehabilitative care.
  • Home health, nursing home, and hospice care.
  • Chiropractic or alternative health care, such as acupuncture.
  • Experimental treatments.

Some plans offer members health education and preventive care, but services differ. Ask questions such as:

  • What preventive care is offered, such as shots for children?
  • What health screenings are given, such as breast exams and Pap smears for women?
  • Does the plan help people who want to quit smoking?

What Is Most Important to Me in a Plan?

In choosing a plan, you have to decide what is most important to you. All plans have tradeoffs. Ask yourself these questions:

  • How comprehensive do I want coverage of health care services to be?
  • How do I feel about limits on my choice of doctors or hospitals?
  • How do I feel about a primary care doctor referring me to specialists for additional care?
  • How convenient does my care need to be?
  • How important is the cost of services?
  • How much am I willing to spend on premiums and other health care costs?
  • How do I feel about keeping receipts and filing claims?

You might also want to think about whether the services a plan offers meet your needs. Call the plan for details about coverage if you have questions. Consider:

  • Life changes you may be thinking about, such as starting a family or retiring.
  • Chronic health conditions or disabilities that you or family members have.
  • If you or anyone in your family will need care for the elderly.
  • Care for family members who travel a lot, attend college, or spend time at two homes.

How Do I Compare Health Plans?

After you review what benefits are available and decide what is important to you, you can compare plans. Many things should be considered. These include services offered, choice of providers, location, and costs. The quality of care is also a factor to think about.

Services 

Look at the services offered by each plan. What services are limited or not covered? Is there a good match between what is provided and what you think you will need? For example, if you have a chronic disease, is there a special program for that illness? Will the plan provide the medicines and equipment you may need?

Find out what types of care or services the plan won’t pay for. These usually are called exclusions.

Few indemnity and managed care plans cover treatments that are experimental. Ask how the plan decides what is or is not experimental. Find out what you can do if you disagree with a plan’s decision on medical care or coverage.

Choice 

What doctors, hospitals, and other medical providers are part of the plan? Are there enough of the kinds of doctors you want to see? Do you need to choose a primary care doctor? If you want to see a specialist, can you refer yourself or must your primary care doctor refer you? Do you need approval from the plan before going into the hospital or getting specialty care?

Location 

Where will you go for care? Are these places near where you work or live? How does the plan handle care when you are away from home?

Costs 

No health insurance plan will cover every expense. To get a true idea of what your costs will be under each plan, you need to look at how much you will pay for your premium and other costs.

  • Are there deductibles you must pay before the insurance begins to help cover your costs?
  • After you have met your deductible, what part of your costs are paid by the plan?
  • Does this amount vary by the type of service, doctor, or health facility used?
  • Are there copayments you must pay for certain services, such as doctor visits?
  • If you use doctors outside a plan’s network, how much more will you pay to get care?
  • If a plan does not cover certain services or care that you think you will need, how much will you have to pay?
  • Are there any limits to how much you must pay in case of major illness?
  • Is there a limit on how much the plan will pay for your care in a year or over a lifetime? A single hospital stay for a serious condition could cost hundreds of thousands of dollars.

You can’t know in advance what your health care needs for the coming year will be. But you can guess what services you and your family might need. Figure out what the total costs to your family would be for these services under each plan.