Choosing a
Health Care Plan
TRADITIONAL
INDEMNITY INSURANCES
- Allow patients
to choose providers freely
- Usually 80% of
provider's fee paid, patient pays 20%
- Deductible
varies according to plan chosen
MANAGED CARE
ORGANIZATIONS (MCO)
Health Maintenance
Organization (HMO)
- Large discounts
on hospital and doctor bills
- Restrictions&endash;HMO
will usually not pay for health services if provider is not in its
network
- Usually require
a referral from the patient's primary care physician
(PCP)
- Usually no
deductible and the co-pay is very low ($5, $10, or $15)
Preferred Provider
Organization (PPO)
- Have a panel of
providers patient can see at a discount (no deductible, low
co-pay)&emdash;generally the least restrictive of managed
care
- Patient may go
"out-of-network" for additional cost (on par with more traditional
insurance)
Point-of-Service
Plan (POS)
- HMO Plan plus,
members can see providers outside the basic HMO by sharing
costs
Dual Choice
Option
Some
insurance companies offer a combination of HMO and PPO (Broader
range of providers, may include deductibles and higher co-pay.
Patient may choose, depending on services needed, to go to someone
on the HMO panel or to select another provider for whatever
reason).
Other
Concerns
- Quality: Check
your MCO for accreditation from the National Committee for Quality
Assurance (an independent, not-for-profit organization that
accredits managed care plans.)
- Is preventive
care available?
- How does your
MCO compare to standards of Health Plan Employer Data and
Information Set (HPEDIS)
- Strong
provider-credentialing
- Solid
relationships with providers
- Efficient
Customer Service Department
- Range of
benefits: medical including mental health, dental, life, long-term
disability and short-term disability
- Prescription
benefits
- Financial
stability: Check its rating on Standard & Poor or A.M.
Best.
- Check out the
state insurance agency. Many states compile statistics on number
of complaints, etc.
Information for
Business Owners choosing a PPO:
- Geographic
access and size of the network (Are there enough providers so that
there is not a long wait and are the sites easily accessible to
most of your employees?)
- Specialties
Included in the Network [and/or provisions for accessing
specialists]&emdash;Cardiac care, Oncology, Mental Health,
Pediatricians, etc.
- Covered
benefits and co-pays (plans do differ)
- Credentialing
process&emdash;How are the providers credentialed?
- Premium
increases&emdash;Ask for history of premium increases
- Where to go for
help&emdash;Does the plan have a good Customer Service
Department?
Summary of
articles, "Health Care & Health Plans: How to Choose a Managed
Care Organization" and "How to Choose a PPO" in "How-To Guide for
Small Business," A Supplement to the San Antonio Business Journal,
pps 18, 20