PRE-ENROLLMENT MARKETING LITERATURE

Prior to a first time enrollment or at your annual open enrollment time, you should carefully review all materials. Enrollment materials usually include:

Marketing materials providing general plan description and history information
A list or chart of covered benefits
Provider directory
Cost sharing and premium price information
Enrollment Application

Some states may have laws that allow potential members to ask the plan for a copy of the policy or certificate of coverage before they enroll. If your state allows this, you should ask for it so you can review all the requirements before you make your final choice.

PROVIDER NETWORK

Review the plans participating provider network in relation to your preferences. Here are just a few of the questions to keep in mind.

Does the plan contract directly with physicians, or primarily with medical groups or with independent practice associations? Which of these arrangements would you feel most comfortable with?
Are the doctors and hospitals located near your home or office?
Do most of their doctors have regular daily office hours? How about extended or weekend hours?
Do you have to select a primary care physician to coordinate your care or can you see their physicians at any time?
Are current physicians that you would like to continue to use part of the network?

BENEFIT COMPARISONS

Carefully review specific benefits covered under the plan. Plans can range from those that just cover a narrow set of basic benefits to those that cover many extras.

What basic benefits are covered?
Are there additional benefits for items such as prescriptions, dental, or vision care?
Review any limitations or special rules.
What services are excluded from the plan?

COST SHARING COMPARISONS

When considering any health insurance or managed care plan, you should carefully consider all out of pocket costs you may be responsible for.

Consider the amount and frequency of premium payments you may have to make.
How much cost sharing (e.g. deductible, co-payments, etc.) will you have?
Will these costs fit within your personal budget?

If cost sharing is high, consider how your budget would be affected if you needed unexpected or long-term health care services.

ELIGIBILITY AND ENROLLMENT REQUIREMENTS

Does the plan have any pre-existing conditions waiting period requirements?
Is coverage available for certain types of dependents (i.e. college students, children of divorced situations, elder guardianships, etc.) outside of your local geographic area?
Does the plan cover services received outside its’ geographical service area or in another state or country?
If you are required to select a primary care physician, under what circumstances can you change to another primary care physician?

MEDICAL MANAGEMENT ACTIVITIES

Most health care organizations (even traditional indemnity insurers) usually have some level of medical management in place. This can range from a few activities (e.g. prior authorization requirements for selected services) to an extensive, comprehensive program (usually found in HMOs). Some questions to keep in mind include:

Do you have to get a referral approved before you can see a specialist?
Do hospital admissions or outpatient procedures require approval before you can receive the services?
Do you have to get authorization if you need care while you are away from your local area?

CUSTOMER SERVICE AND SATISFACTION

Many plans offer similar benefits and little difference in premium or out of pocket costs. This may make it hard to choose the plan that is best for you. One of the ways health care organizations may differ is in the type of customer service they provide. It may also be helpful to know how satisfied members and providers are with the organizations’ service and programs.

Ask friends, relatives, or co-workers enrolled in the plan, how satisfied they are
If your physician is contracted with the plan, ask how satisfied they are with the plans’ procedures

Check to see if the plan is accredited or certified by a nationally recognized organization.

What kind of complaint and appeal resolution process does the plan have?

Check with consumer groups or state and federal regulatory agencies to see if there are any positive or negative reports on the plan.