Time for annual health plan check up

The annual window for changing your health plan option will open as soon as the premium rates for 2005 are set. This is likely to take place in November.

You will have 30 days after the rates are delivered to the state agencies to change health plans. If you don’t request a change during that period, you will automatically remain enrolled with the same health plan you are in.

Not all health plans are alike, and the one that was the best for you this year may no longer be your best choice. It’s well worth your effort to compare them.

Empire Plan or HMO?

Consider such factors as accessibility, benefits, quality, cost and ask yourself these questions:

• W hat are the potential out-of-pocket expenses?  These expenses can include deductibles, coinsurance costs, copayments, and non-covered expenses such as charges by health care providers that exceed the maximum allowed under the plan's reimbursement schedule.

For instance, if you are enrolled in the Empire Plan and use a non-participating provider, benefits will be provided under the Basic Medical Program.  You must first meet the annual deductible and then the plan will pay 80 percent of the total charge or the Reasonable and Customary (R&C) charge, whichever is less.  You are responsible for the difference between the provider’s total charge and the reimbursement amount you receive from United HealthCare.

• Are you required to file your own claims? If so, what is the process for filing claims?  How long does it take to be reimbursed or to dispute a claim determination?

HMO enrollees often report less paperwork and administrative hassle than those enrolled in a fee-for-service plan like the Empire Plan.

• W hat are your health-care needs? Do you or a dependent require services for a ch ron ic medical condition or mainly for acute or urgent conditions?  W hich plans cover these services and how extensive is the coverage?  Does the plan insure against serious financial losses?

W hat benefits are available for the treatment of mental health conditions and alcohol or chemical dependency?  W hat facilities and clinicians in your area are affiliated with the plan?

Look for any contract provisions or plan procedures that restrict your access to care or limit the benefits available.

• W hat benefits are available for prescription drugs?  Do you have the option of using a mail-order pharmacy for maintenance drugs? Is the copayment less if you use the mail-order pharmacy? W hat is the copayment for up to a 90-day supply of maintenance drugs? Are benefits provided for all FDA-approved drugs or limited to only those drugs included on a formulary (list of preferred drugs)? How often are changes made to the preferred drug list (formulary)? Is there a mandatory generic-drug substitution requirement?

The Empire Plan, as well as twelve of the thirteen HMO options, have a three-tier prescription drug benefit design.  You will pay more for brand-name drugs that are not on the plan’s preferred list (formulary).

• W ho are the providers affiliated with the plan?  Are there an adequate number of providers? How many of the plan’s physicians are board-certified or board-eligible?

"Board certification" means the doctor has had two or more years of training in a specialty field after medical school and has then passed a national exam.  Doctors who have completed the training but not the exam are board-eligible.  W hen looking for a good doctor, board certification is an important consideration.

• How important is it to keep the doctor you have?  Does the plan restrict your ability to use providers of your choice? W ill you need a referral to see a specialist?

Under a managed care program, benefits may be denied or reduced if you don’t use a participating provider, or if you receive services from a specialist (even one affiliated with the plan) without a referral. 

• W hat if you use a non-participating provider? W ill you receive any benefits at all under the plan? HMOs do not provide benefits for non-participating providers under most circumstances. The Empire Plan provides benefits for services performed by participating and non-participating providers, including the Basic Medical Discount Provider Program (MultiPlan network). You receive the highest level of benefits when you use a participating provider.

• How will your doctor’s reimbursement affect your care?  Does the plan penalize your doctor financially if you need frequent visits, referrals, or expensive tests and treatments?

Doctors may be paid by: salary; fee-for-service; fee-for-service less a withhold; or capitation (the same payment per patient no matter how many or how few services you receive). 

• W ill coverage be limited if you or a covered dependent needs medical care while out of the plan’s service area? Many HMOs provide very limited benefits for care received outside their service areas.  If you travel or have dependent children who live or attend college outside of an HMO's service area, pay particular attention to the criteria that must be met to receive benefits.  Your child may have to return home for non-urgent medical care.

Finally, you may want to ask these questions:

·         Is medical case management available?

·         W hat services require prior authorization and what are the notification requirements?

·         W hat are the penalties for non-compliance? How can you appeal a denial of benefits?