| | Choosing a Health Insurance Plan Contents
Today there are more Health Insurance Plans to choose from than ever before. Not
everyone has a choice. But if you do, this section can help you choose
the plan that offers the best quality for you and your family.
Research shows that people say that quality is the most important
thing they think about when choosing a health plan. But research also
shows that few people understand their options well enough to make an
informed choice. Quick Check for Quality
Look for a plan that:
[x] Has been rated highly by its members on the things that are
important to you.
[x] Does a good job of helping people stay well and get better.
[x] Is accredited, if that is important to you.
[x] Has the doctors and hospitals you want or need.
[x] Provides the benefits you need.
[x] Provides services where and when you need them.
[x] Meets your budget.
Your Health Insurance Plan Affects Many Things - Who will care for you (doctors and other health care providers),
and how much choice you will have.
- What kind of care you will receive (for example, which preventive
services are covered?).
- Where you will receive your care (which hospitals, for example).
- When you will receive your care (will you receive it when you need
it?).
- How you will be cared for (the quality of care you receive).
- How much you will pay.
How to Make Decisions Based on Quality
The next section lists several questions you may want to consider when
choosing a health plan. These questions are based on research about
what consumers want to know when choosing Health Insurance Plans. Under each
question you will find more information to help you choose the plan
that is right for you. You also will find a way to compare the health
plans you are looking at. Here's how:
Space is provided for comparing three plans. Please enter the name of
each plan on a separate line (Plan A, B, and C).
Plan A: ___________________________
Plan B: ___________________________
Plan C: ___________________________
Read the questions. Which are most important to you in choosing a
health plan?
Read and think about the information under each question. Then ask
yourself the question. If the answer is "yes" for a plan, check the
box next to its name.
Of course, the answers to these questions may not be as simple as
"yes" or "no." Still, these questions should help you to think about
and compare your health plan choices.
Do this for all the questions you have chosen. Rate Your Health Insurance Plan Choices Do members rate the plan highly on things that are important to me?
Plan A: [_] Yes
Plan B: [_] Yes
Plan C: [_] Yes
Before you join a plan, it is hard to know what kind of care you will
get. One way to find out is to learn what members of the plan say
about it. This kind of information is called consumer ratings or
consumer satisfaction information. Does the plan provide preventive services to help keep people well?
Plan A: [_] Yes
Plan B: [_] Yes
Plan C: [_] Yes
Does it do a good job of helping them get better when they are sick?
Plan A: [_] Yes
Plan B: [_] Yes
Plan C: [_] Yes
Is the plan accredited?
Plan A: [_] Yes
Plan B: [_] Yes
Plan C: [_] Yes
Many Health Insurance Plans choose to be reviewed and accredited. Does the plan have the doctors and hospitals I want or need?
Plan A: [_] Yes
Plan B: [_] Yes
Plan C: [_] Yes
Here are some questions to think about: - Are you happy with your current doctors?
Call their offices to find out which plans they are in. You may be
able to choose a plan that will allow you to keep seeing those
doctors without paying extra.
- Do you want to make sure the plan includes the kinds of doctors you
will want to see?
Call the plans you are looking at to get a list of their doctors
and other providers.
And remember, the hospital you go to often depends on the plan you are
in and where your doctor has privileges. If going to a certain
hospital is very important to you, keep that in mind when choosing a
plan. Does the plan provide the benefits I need?
Plan A: [_] Yes
Plan B: [_] Yes
Plan C: [_] Yes
Insurance plans vary. Before choosing a plan, decide what is most important to you. This checklist can help.
Put a check in front of those services that are important to you. Then see how many of these services are in Plan A, Plan B, and Plan C.
On the checklist, write in the coinsurance or copayment rate, if there is one, and any limits on service.
Remember that the most important service to be covered is hospitalization. Which health care services are most important to you and your family?
Do the plans you are comparing provide these services?
If you are not covered for hospital care, then one sickness could cost you thousands of dollars,
even hundreds of thousands of dollars. There are extra spaces at the end of
the list in which to add other services. | Are These Services Covered?
| Plan A
| Plan B
| Plan C |
Cancer screening (colorectal cancer
tests, mammograms, Pap smears, etc.)
| [_]
| [_]
| [_]
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Cholesterol screening
| [_]
| [_]
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Immunizations (shots)
| [_]
| [_]
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Prenatal care
| [_]
| [_]
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Well-baby care
| [_]
| [_]
| [_]
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Care for a pre-existing condition (one
you have before joining the plan)
| [_]
| [_]
| [_]
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Dental exams/treatments
| [_]
| [_]
| [_]
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Eye exams/glasses/contact lenses
| [_]
| [_]
| [_]
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Hearing exams/hearing aids
| [_]
| [_]
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Outpatient prescription medicines
| [_]
| [_]
| [_]
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Medical equipment for use at home
| [_]
| [_]
| [_]
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Mental health services
| [_]
| [_]
| [_]
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Physical therapy
| [_]
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Hospice care
| [_]
| [_]
| [_]
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Counseling to stop smoking
| [_]
| [_]
| [_]
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Drug and alcohol counseling
| [_]
| [_]
| [_]
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Alternative treatments (such as
acupuncture or chiropractic services)
| [_]
| [_]
| [_]
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Home health care
| [_]
| [_]
| [_]
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Adult day care
| [_]
| [_]
| [_]
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Nursing home care
| [_]
| [_]
| [_]
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______________________________
| [_]
| [_]
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______________________________
| [_]
| [_]
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______________________________
| [_]
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______________________________
| [_]
| [_]
| [_]
| Do the doctors, pharmacies, and other services in the plan have
convenient times and locations?
Plan A: [_] Yes
Plan B: [_] Yes
Plan C: [_] Yes
Here are some questions you may want to call the plan to find out: Are the services close enough to home or work?
Are they on convenient routes for public transportation?
Is parking available?
Are offices open in the evenings and on weekends?
Does the plan meet my budget?
Plan A: [_] Yes
Plan B: [_] Yes
Plan C: [_] Yes
Use the health plan materials from your employer or the plans to
answer these questions and enter the information on the line provided
under each plan. | Cost
| Plan A
| Plan B
| Plan C |
How much will the premium cost me
each month?
| _______
| _______
| _______
|
If there is a deductible, how much will I
have to pay before the plan starts to pay
for medical care?
| _______
| _______
| _______
| |
For prescription medicines?
| _______
| _______
| _______
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How much will I have to pay
(co-payment) each time I have a Doctor visit?
| _______
| _______
| _______
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How much will I have to pay
(co-payment) each time I have a Hospital visit ?
| _______
| _______
| _______
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How much will I have to pay
(co-payment) each time I have a Prescription?
| _______
| _______
| _______
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How much more will I need to pay if I go
outside the health plan's network of
doctors, hospitals, and other providers to
get services?
| _______
| _______
| _______
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Which policy is best for you? What are the weighting period?
Only treatment for accidents is covered when you first join most health funds or upgrade your health insurance.
There are usually three main areas where waiting periods apply before you can make a claim:
- 2 months before new members can make a claim. From time to time private health funds run promotions offering "immediate" cover to new members - this "immediate" cover usually does NOT apply to obstetrics and pre-existing ailments.
- 12 months for obstetrics and maternity claims.
- 12 months for pre-existing ailments and conditions. Funds firmly apply this rule - so, if you're not certain how this may affect your cover, ask the funds staff to explain the rule. Remember, even undiagnosed illnesses may not be covered by your health insurance policy.
Many policies incorporate other waiting periods for 'ancillary' benefits such as dental and optical work; and lengthy waiting periods for some specific medical and surgical procedures, such as cosmetic surgery and IVF.
Note that waiting periods apply to the additional benefits members get when they upgrade their health insurance.
Waiting periods can be extended further by 'benifit limitation periods'.
Plan A: [_] Yes
Plan B: [_] Yes
Plan C: [_] Yes
What is included in the health insurance policy fineprint?
Plan A: [_] Yes
Plan B: [_] Yes
Plan C: [_] Yes
Policies offered by private health funds include conditions, exclusions and explanations in the 'fine print' attached to their brochures and applications forms. Read the 'fine print' before signing. Policies are also called 'tables' or 'products'.
If you do not understand the 'fine print,' ask the health fund to explain.
For example, a health insurance policy might exclude important things like heart surgery or hip replacements.
Please read your fund's brochure to familiarise yourself with what your health insurance policy covers and what it doesn't.
All health insurance products are NOT the same.
Understand what benefit limitation periods apply?
Plan A: [_] Yes
Plan B: [_] Yes
Plan C: [_] Yes
Some funds impose benefit limitation periods on new members, people transferring from other funds and existing members upgrading their policies. These limitations effectivly impose additional waiting periods for the payment of benefits above the default benefit amount. For example, a new member might have to wait for a year before default benefits are paid for certain treatment and then more time before full benefits are paid. (Default benefits are often only about half the fees for accommodation in private hospitals and do not cover theatre and some other costs).
Understand how policy limits, excesses and co-payments are calculated
Plan A: [_] Yes
Plan B: [_] Yes
Plan C: [_] Yes
Many health insurance policies place a limit on claims, particularly those for "ancillary" benefits such as dental and optical services. For example, you may only be able to claim up to $750 for fillings or other dental work in any 12 month period.
Many funds have products with excesses. By agreeing to pay the first part of your bill, from anywhere between $100 and $1000, you can reduce your premiums.
A few funds require members to pay a daily amount towards their hospitals bills called co-payments.
There are a number of ways that health funds apply limits, excesses and co-payments. It is important for you to understand this before selecting a policy. Ask your fund for details.
Does the health insurance funds offer overseas cover?
Plan A: [_] Yes
Plan B: [_] Yes
Plan C: [_] Yes
Many health insurers will not pay for any overseas medical treatment. Other health funds will only make payments at Australian fee levels - which are well below the cost of medical treatment in the USA, Europe and many other countries.
Before leaving Australia, you should ask your health fund if your health insurance policy covers you for overseas medical expenses.
Also, if you suspend your health insurance policy while you are overseas, some funds will impose waiting periods for certain treatment when you return. Check the rules about this with your health fund before you go.
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