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Choosing Health Care Coverage: Issues and Options

As the year concludes, many of us are tasked with electing our healthcare plan for next year. External factors, not in our control, influence what our healthcare costs are going to be. The overall economic slowdown and rising federal deficit, has placed great strain on the systems that have traditionally financed health care, including private employer-sponsored health insurance coverage and public insurance programs such as Medicare and Medicaid. Since 1999, family premiums for employer-sponsored health coverage have increased by 131%, while real wages are growing at a much slower pace or have even stagnated in many industries.  

This is my year to switch from the healthcare plan provided by my husband’s law firm to Medicare Part B and a Medigap program.  I am making the change because I will save several thousand dollars, now that I have reached the magic age where I qualify for this coverage. Trying to figure out how to get the best health care benefits from what is available, and understand the rules and regulations presented in the Medicare Subscriber Handbook, Medicare and You, 2012 or on the website www.medicare.gov is akin to wading through Chaucer in old English. 

So I asked my friends and colleagues which plan they were using and why.  I talked with my healthcare providers to find out if there were Medigap plans that they would not accept, to determine which plans were going to allow me to keep the same physicians and hospital that I have been using for years. I spoke with several health plans and did an extensive comparison of their benefits and payment process. I read articles on the web and looked at plan ratings.  Armed with all that information, I made a choice that I am comfortable with.   

You also need to research your options if you are to get the best plan for you and your family. Among the questions that you need to ask when choosing your health plan are the following:

  • Does the plan provide the specific benefits and services tailored to your needs? Are those services available quickly and efficiently?
  • How much is the monthly premium and what does that total for a year?
  •  What does the policy cover for specific health events?  Does it include prescription drugs, out of hospital care, rehabilitation or home care? Does it include lab fees and emergency room visits? Do you have the option to see a specialist and what are the out of pocket costs?
  • Are there limits on the number of days insurance will pay for hospital or rehab services?
  • Are there some medical conditions that are not covered by the plan?
  • Are there waiting periods involved with coverage?
  • What is the deductible?  Can you lower the monthly premiums by raising the deductible?
  • Is there a maximum that you must pay out of pocket per year?
  • Is there a lifetime maximum cap that the insurance will pay?
  • Can you go to the physicians and hospitals best situated for you?  How easy is it to see a specialist?
  • How is the plan ranked against its competitors and by its subscribers?
  • Do members get the therapy treatments they need?
  • Does the plan provide preventive/wellness services?
  • Is the plan accredited? The National Committee for Quality Assurance (NCQA, www.ncqa.org) evaluates and rates plans on several quality measures as does the Joint Commission on Accreditation of Healthcare Organizations (JCAHO www.jcaho.org).  A visit to the websites of either of these organizations can give you rating information at no charge.

 Additionally, you need to make sure that the policy protects you from excessive medical costs that you might face, particularly if you have ongoing medical issues. Read the fine print to make sure there are no contingencies regarding what is covered and what is not.  Understand, as an outpatient and inpatient, the benefits and co-payments you are required to make, and whether or not there is an annual deductible before the policy will start to pay. Know exactly what may be excluded from your coverage (certain diseases, therapies, procedures) and understand the added benefits such as membership in a health club or an allowance towards a weight loss program.

(These points and questions and more are discussed in my book: e-Patients Live Longer, The Complete Guide to Managing Health Care Using Technology.)

Health care is no longer a given where you sign on the bottom line and are insured for another year.  It is a major item in your annual budget, and when those forms come across your desk, take the time to do the research, ask the right questions and read the fine print for a better, more economical and healthier New Year.

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