Choosing the right health plan is important.

Making a good decision about is not an easy thing to do. There is no exact way of knowing which health insurance plan is the best deal. Why?

To compare cost across the system, you need both the monthly premium and the contracted rates for the plan. The monthly premium is what you pay for health insurance and the contracted rates are what the plan and you to some degree pays for healthcare services. Unfortunately, the information is not readily available to healthcare consumers [aka: you].

Health Insurance vs. Healthcare Providers

Many insurance companies operate independent of healthcare providers that provide healthcare services. Kaiser Permanente [aka: KP] is the exception. KP is organized as a staff model HMO meaning they own and operate the insurance company and all the different provider organizations in their system. When you join KP as a member, you are expected to use only the providers in their system. If you venture out of the KP system, expect to pay for the full cost of those healthcare service out of your pocket.

Commercial Carriers

Commercial insurers such as United, Cigna, Aetna, BCBS contract with healthcare providers to provide you with a network of service providers. Healthcare consumers who choose a commercial insurer do so to have more choice and control of their healthcare options and healthcare spending. Choosing the right insurer takes a little research to ensure your doctors are in the network.

Five questions to answer when choosing a health plan

1/ Do you have a primary care physician [PCP]? 

If you already have a PCP, make sure they are in the network for all the insurers that you’re considering. If you don’t have a PCP, search for one that is either close to your home or office. At a minimum, take the time to meet them and tour the office, ask if they are accepting new patients and how long it will take to get an appointment. They should also be able to give you a good estimate for an office visit and annual exam.

The cost of a Medicare physician visits in 2019 will be $130 – $212 for new patient visits and $90 – $149 for repeat client depending on complexity. Medicare rates are typically lower than commercial rates but serve as a good benchmark.

2/ What plans [HMO, PPO, EPO etc.] does your PCP accept?

Some healthcare providers only accept PPO plans because they don’t want to deal with the added restrictions of being a HMO and EPO provider. HMO and EPO plans often negotiate lower prices with healthcare providers in exchange for more patients, but the plans also have restrictions on the types and number of services that can be provided.

Expensive services and innovative treatments need to be pre-authorized by the plan. All that “red tape” is difficult for providers to manage which is why some don’t accept HMO and EPO plans.

3/ Which medical group is your PCP affiliated with?

If you choose an HMO, ask your PCP for their medical group affiliation. Most if not all, will be apart of a larger network of physicians who accept financial responsibility for managing your healthcare. It’s good to know who is really holding the purse strings on the plan you choose.

4/ Which hospitals and other facilities does your PCP use?

If you routinely use hospital services or partake in risky activities, ask for your PCP which hospital they use. Physicians often have privileges at more than one facility. It’s good to know what the options are in advance because the quality and price varies facility to facility.

5/ Do the hospitals and others meet your expectations?

The plans should have a way to show you which hospitals in their network are the best deal in terms of cost and quality. In healthcare, higher cost doesn’t necessarily equate to better quality. If you use hospitals and other facilities regularly, look at the data.

Best Advice 

Buy enough health insurance so that the cost of healthcare services doesn’t prevent you from seeing a doctor when you’re sick or just not feeling yourself.

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