Whether your open-enrollment package hits your desk in a 9-by-12 packet or invades your PC in data packets, those promotional materials, charts and check-offs describing your health insurance choices can drown you in a sea of disclaimers, exceptions and other maddening complications.
The trouble is that when you’re neck-deep in the details of your lesser-of-evils healthcare choices, it’s too easy to lose sight of what should be your guiding question: Which plan will best enable you to stay well and get the highest-value care when you’re sick?
So let’s take a look at the big picture, with the help of a few health insurance experts. If you want to dig deeper, check out the US Department of Health and Human Services’ “Questions and Answers About Health Insurance: A Consumer Guide.”
Put Quality First
Here’s a radical idea: Even if you devote most of your healthcare anxiety to containing healthcare's enormous and growing cost, you should consider quality of care before anything else. What could be more expensive -- in money, time, suffering and stress -- than failing to receive optimal care for a medical problem?
If you’ve got a primary-care physician or specialist you like, you might make that preference a driving force when choosing an insurer.
“A lot of smart people work back from the provider they want,” says James Walsh, an insurance expert and president of Silver Lake Publishing, which publishes books advising consumers on insurance issues. “Go to the practitioner and ask them what insurance companies they accept.”
But don’t stop there. Look for a report card on your employer’s health plans at the National Committee for Quality Assurance. Caveat: This group gets some funding from healthcare companies. Also check with your state insurance department for complaints against health plans.
Finally, examine the performance of the full range of a particular health plan’s care providers. “Check to see if your health plan’s Web site provides health outcomes ratings of hospitals and specialists,” says Joseph Mondy, an assistant vice president at insurer Cigna HealthCare.
Avoid Plans that Spurn Wellness and Prevention
Wellness programs and coverage for preventive care are on the upswing, but many health plans still give them short shift.
And the quality of these programs is a matter of life and death. If all health plans provided the same disease-prevention and wellness programs and best-practice treatments as the nation’s top 10 percent of health plans, each year up to 81,000 deaths could be avoided, according to a Consumer Reports’ summary of research into health plans.
Whatever plan you choose, be sure it covers prevention, rather than making you pay for routine exams and screenings as some high-deductible health plans do, often in exchange for lower premiums. “First-dollar coverage for preventive and wellness programs is a very important feature,” says Robert Cimasi, president of Health Capital Consultants in St. Louis.
Now Tackle the Cost Beast
Before choosing a plan, most of us need to consider its cost. But don’t take just the payroll deduction into account. Make sure you factor in all of these potential costs:
- Employee-paid premiums.
- Coinsurance, which requires you to pay a percentage of the total cost of care.
- Maximum annual out-of-pocket expense.
- Healthcare services the insurer doesn’t cover.
Does your company give you a way to compare your alternatives dynamically? If so, take advantage. “Leading health plans offer online financial modeling tools to estimate your annual costs based on the plans offered, your family demographics and past medical bills,” Mondy says.
If you’re considering a consumer-driven healthcare plan, be sure you understand how it works. “With a high-deductible plan and a medical savings account, you’ll be paying out of pocket, so you’ve got to be a smart shopper,” Walsh says.
And if you use -- or plan to open -- a tax-advantaged health savings account to pay your out-of-pocket expenses, “be aware of how much of that money can be rolled over if you don’t use it” during the plan year, Cimasi says.
Also, “make sure that if you want to see healthcare providers out of network, those providers will accept a PPO rate, which might be $60 for a doctor visit instead of $250,” he says.
According to Walsh, healthcare providers and plan administrators may be more flexible than you might think. Whether you’re hoping your employer will consider adding an insurance program to its offerings or that your physician will work out a payment schedule with you, “it’s all very negotiable,” Walsh says.