Frequently Asked Questions

Choosing and Using a Health Plan
What you should know about the different types of health plans that are available today.


The Agency for Health Care Policy and Research

Changes and Choices
Health care in America is changing rapidly. Twenty-five years ago, most people in the United States had indemnity insurance coverage. A person with indemnity insurance could go to any doctor, hospital, or other provider (which would bill for each service given), and the insurance and the patient would each pay part of the bill.
But today, more than half of all Americans who have health insurance are enrolled in some kind of managed care plan, an organized way of both providing services and paying for them. Different types of managed care plans work differently and include preferred provider organizations (PPOs), health maintenance organizations (HMOs), and point-of-service (POS) plans.
You've probably heard these terms before. But what do they mean, and what are the differences between them? And what do these differences mean to you?
Overview
This article can help you make sense of your choices for getting health care insurance:

  • See the questions and answers on important things you should know when "Choosing a Plan."
  • To get the most out of the plan you choose, see the tips in the section "Using Care."
  • For more help, see "Sources of Additional Information."

Even if you don't get to choose the health plan yourself (for example, your employer may select the plan for your company), you still need to understand what kind of protection your health plan provides and what you will need to do to get the health care that you and your family need.
The more you learn, the more easily you'll be able to decide what fits your personal needs and budget.

Choosing a Plan

Where Do I Get These Health Plans?

Group Policies
You may be able to get group health coverage -- either indemnity or managed care -- through your job or the job of a family member.
Many employers allow you to join or change health plans once a year during open enrollment. But once you choose a plan, you must keep it for a year. Discuss choices and limits with your employee benefits office.

Individual Policies
If you are self-employed or if your company does not offer group policies, you may need to buy individual health insurance. Individual policies cost more than group policies.
Some organizations -- such as unions, professional associations, or social or civic groups -- offer health plans for members. You may want to talk to an insurance broker, who can tell you more about the indemnity and managed care plans that are available for individuals. Some States also provide insurance for very small groups or the self-employed.

Medicare
Americans age 65 or older and people with certain disabilities can be covered under Medicare, a Federal health insurance program.
In many parts of the country, people covered under Medicare now have a choice between managed care and indemnity plans. They also can switch their plans for any reason. However, they must officially tell the plan or the local Social Security Office, and the change may not take effect for up to 30 days. Call your local Social Security office or the State office on aging to find out what is available in your area.
Medicaid
Medicaid covers some low-income people (especially children and pregnant women), and disabled people. Medicaid is a joint Federal-State health insurance program that is run by the States.
In some cases, States require people covered under Medicaid to join managed care plans. Insurance plans and State regulations differ, so check with your State Medicaid office to learn more.

Pre-Existing Conditions
A pre-existing condition is a medical condition diagnosed or treated before joining a new plan. In the past, health care given for a pre-existing condition often has not been covered for someone who joins a new plan until after a waiting period. However, a new law -- called the Health Insurance Portability and Accountability Act -- changes the rules.
Under the law, most of which goes into effect on July 1, 1997, a pre-existing condition will be covered without a waiting period when you join a new group plan if you have been insured the previous 12 months. This means that if you remain insured for 12 months or more, you will be able to go from one job to another, and your pre-existing condition will be covered -- without additional waiting periods -- even if you have a chronic illness.
If you have a pre-existing condition and have not been insured the previous 12 months before joining a new plan, the longest you will have to wait before you are covered for that condition is 12 months.
To find out how this new law affects you, check with either your employer benefits office or your health plan.

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What Is Most Important to Me in a Plan?
In choosing a plan, you have to decide what is most important to you. All plans have tradeoffs. Ask yourself these questions:

  • How comprehensive do I want coverage of health care services to be?
  • How do I feel about limits on my choice of doctors or hospitals?
  • How do I feel about a primary care doctor referring me to specialists for additional care?
  • How convenient does my care need to be?
  • How important is the cost of services?
  • How much am I willing to spend on premiums and other health care costs?
  • How do I feel about keeping receipts and filing claims?

You might also want to think about whether the services a plan offers meet your needs. Call the plan for details about coverage if you have questions. Consider:

  • life changes you may be thinking about, such as starting a family or retiring
  • chronic health conditions or disabilities that you or family members have
  • if you or anyone in your family will need care for the elderly
  • care for family members who travel a lot, attend college, or spend time at two homes

How Do I Find Out about Quality?
Quality is hard to measure, but more and more information is becoming available. There are certain things you can look for and questions you can ask. Whatever kind of plan you are considering, you can check out individual doctors and hospitals. For doctors, see "Tips on Choosing a Doctor."
Many managed care plans are regulated by Federal and State agencies. Indemnity plans are regulated by State insurance commissions. Your State Department of Health or insurance commission can tell you about any plan you are interested in.
You can also find out if the managed care plan you are interested in has been "accredited," meaning that it meets certain standards of independent organizations. Some States require accreditation if plans serve special groups, such as people in Medicaid. Some employers will only contract with plans that are accredited.
Several national organizations review and accredit plans and institutions (see "Sources of Additional Information"). You can contact these organizations to see if a plan you are considering, or an institution in the plan, is accredited.
Another approach is to ask the plan how it ensures good medical care. Does the plan review the qualifications of doctors before they are added to the plan? Plans are supposed to review the care that is given by their doctors and hospitals. How does the plan review its own services, and has it made changes to correct problems? How does the plan resolve member complaints?
Some managed care plans survey members about their health care experiences. Ask the plan for a report of the survey results.
Some plans and independent organizations are also beginning to produce "report cards." These reports often include satisfaction survey results and other information on quality, such as if a plan provides preventive care (for example, shots for children and Pap smears for women) or if the plan follows up on test results. Report cards may also include information on how many members stay in or leave the plan, how many of the plan's doctors are board certified, or how long you may have to wait for an appointment.
Report cards can only give you an idea of how a plan works and may not give a full picture of a plan's quality. Ask plans if their activities have been reported in report cards developed by outside groups (business or consumer organizations).
Also keep any eye out for magazine articles that rate health plans.
Finally, you can talk to current members of the plan. Ask how they feel about their experiences, such as waiting times for appointments, the helpfulness of medical staff, the services offered, and the care received. If there are programs for your particular condition, how are the patients in it doing?

Tips on Choosing a Doctor
Your doctor will be your partner in care, so it is important to choose carefully from the doctors available to you. In some managed care plans, you will generally be limited to choosing from only certain doctors; in other plans, some doctors may be "preferred," which means they are part of a network and you will pay less if you use them. Ask your plan for a list or directory of providers. The plan may also offer other help in choosing.
You can ask doctors you know, medical societies, friends, family, and coworkers to recommend doctors. You may also contact hospitals and referral services about doctors in your area.
Once you have the names of doctors who interest you, make sure they are accepting new patients. Here's how to check doctors out:

  • Ask plans and medical offices for information on their doctors' training and
    experience.
  • Look up basic information about doctors in the Directory of Medical Specialists, available at your local library. This reference has up-to-date professional and biographic information on about 400,000 practicing physicians.
  • Use "AMA Physician Select," which is the American Medical Association's free service on the Internet for information about physicians ( http://www.ama-assn.org/aps/amahg.htm ).

You may also want to find out:

  • Is the doctor board certified? Although all doctors must be licensed to practice medicine, some also are board certified. This means the doctor has completed several years of training in a specialty and passed an exam. Call the American Board of Medical Specialties at 800-776-2378 for more information.
  • Have complaints been registered or disciplinary actions taken against the doctor? To find out, call your State Medical Licensing Board. Ask Directory Assistance for the phone number.
  • Have complaints been registered with your State department of insurance? (Not all departments of insurance accept complaints.) Ask Directory Assistance for the phone number.

Once you have narrowed your search to a few doctors, you may want to set up "get acquainted" appointments with them. Ask what charge there might be for these visits, if any. Such appointments give you a chance to interview the doctors -- for example, to find out if they have much experience with any health conditions you may have.

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How Do I Obtain Care?
Learning what you can expect from your health plan and how it works are key steps to getting the care you need. Ask these questions:

  • When are the offices open? What if I need care after hours?
  • How do I make appointments? How quickly can I expect to be seen for illness or for routine care?
  • If I need lab tests, are they done in the doctor's office or will I be sent to a laboratory?
  • Will most of my appointments be with the primary care doctor? Will nurse practitioners or physician's assistants sometimes give care as well?
  • Is there an advice hotline? Some plans have toll-free phone services that help members decide how to handle a problem that may not require a doctor's visit.

Find out how your plan provides care outside the service area and what you must do to get care. This is especially important if you travel often, are away from home for long periods, or have family members away at school.

What If I Am Not Satisfied with My Care?
Getting the best care and services means understanding how your health plan works, what your rights are, and how to complain if you need to. You have the right to get copies of test results as well as medical information about yourself. If you are in a managed care plan, you can ask to change your primary care doctor if you are unhappy with the relationship. You may also be able to switch plans during open enrollment.
Most plans have an appeals process that both you and your doctor may use if you disagree with the plan's decisions. If your plan refuses to provide or pay for services, you can complain or file a grievance about any decision you feel is unfair -- or you can appeal it.
You can contact the member services division of your plan for more information or to complain. Use your plan's complaint process fully before taking other action.
Be sure to keep written records of:

  • all correspondence with the plan
  • claims forms and copies of bills
  • phone conversations -- the date and time, the people you speak with, and the nature of each call

If the plan does not satisfy you, you may decide to bring the matter to the attention of your employee benefits manager, your State insurance commissioner, your State department of health, or the legal system. If you are a Medicare or Medicaid beneficiary, you have additional ways through those programs to file a grievance about the care received from a plan or provider. For information, contact your State's medical Peer Review Organization or State Medicaid Program.

Sources of Additional Information
Many organizations have information that can help you understand your health care choices. Some helpful materials and contacts are listed.

General Information
Checkup on Health Insurance Choices
Questions To Ask Your Doctor Before You Have Surgery

Agency for Health Care Policy and Research
Publications Clearinghouse
P.O. Box 8547
Silver Spring, MD 20907
800-358-9295
The Consumers Guide to Health Insurance

Health Insurance Association of America
555 13th St. N.W., 600 East
Washington, DC 20004-1109
(202) 824-1600
Guide to Health Insurance for People with Medicare
Your Medicare Handbook
Managed Care Plans

Health Care Financing Administration
7500 Security Blvd.
Baltimore, MD 21244-1850
800-638-6833
Putting Patients First

National Health Council
1730 M St., NW, Suite 500
Washington, DC 20036-4505
(202) 785-3910
Managed Care: An AARP Guide

American Association of Retired Persons
611 E St., N.W.
Washington, DC 20049
(202) 434-2277
Choosing Quality: Finding the Health Plan That's Right for You

National Committee for Quality Assurance
2000 L St., N.W., Suite 500
Washington, DC 20036
800-839-6487
Consumers' Guide to Health Plans

Consumers' Checkbook
Center for the Study of Services
733 15th St., N.W., Suite 820
Washington, DC 20005
(202) 347-7283

Accreditation and Quality
Accreditation Association for Ambulatory Health Care; 9933 Lawler Ave.; Skokie, IL 60077-3708; (847) 676-9610
Accredits outpatient health care settings such as ambulatory surgery centers, radiation oncology centers, and student health centers. Call for a list of accredited organizations.

Community Health Accreditation Program; 350 Hudson St.; New York, NY 10014; 800-669-1656, ext. 242
Accredits community, home health, and hospice programs; public health departments; and nursing centers. Call for a list of accredited organizations.

Consumer Coalition for Quality Health Care; 1275 K Street, N.W.; Suite 602; Washington, DC 20005; (202) 789-3606
A national, nonprofit organization of consumer groups advocating for consumer protections and quality assurance programs and policies. Call with general questions about quality issues or for consumer materials on managed care and activities at the State level.

Joint Commission on Accreditation of Healthcare Organizations; One Renaissance Blvd.; Oakbrook Terrace, IL 60181; (630) 792-5000
Evaluates and accredits nearly 20,000 health care organizations and programs including almost 12,000 hospitals and home care organizations, and more than 7,000 other health care organizations that provide long term care, behavioral health care, laboratory and ambulatory care services. The Joint Commission also accredits health plans, integrated delivery networks, and other managed care entities. Visit Quality Check on the Joint Commission's Web site ( http://www.jcaho.org ) for information on individual accredited organizations or for general information about assessing the quality of health care organizations.

National Committee for Quality Assurance; 2000 L St. N.W., Suite 500; Washington, DC 20036; 800-839-6487; Web Site: http://www.ncqa.org
Accredits HMOs and other managed care organizations. Call for the NCQA Accreditation Status List, Accreditation Summary Report, publications list, or for general information about quality.

Utilization Review Accreditation Commission; 1130 Connecticut Ave. N.W., Suite 450; Washington, DC 20036; (202) 296-0120
Accredits PPOs and other managed care networks. Call for a list of accredited organizations.
This consumer's guide was developed by the Agency for Health Care Policy and Research, U.S. Department of Health and Human Services, Rockville, MD, in cooperation with the Health Insurance Association of America, Washington, DC.
Reviewed by Michael W. Smith, MD, April 2002.


"Agency for Health Care Policy and Research. ACER Publication: Choosing and Using a Health Plan. Last updated March 1999. (Online) http://www.ahcpr.gov/consumer/hlthpln1.htm"

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