By LORRAINE SIMPKINS
The annual window for changing your health-plan option will open as soon as the premium rates for 2001 are set. This is likely to take place in November.

You will have 30 days after 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 best for you this year may no longer be your best choice. It’s well worth your effort to compare them.

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

• What are your 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 a plan’s reimbursement schedule.

For instance, if charges for services covered under the Basic Medical portion of the Empire Plan exceed the “reasonable and customary (R&C) charge” for those services as determined by the administrator, United HealthCare, you will have to pay the difference.

• Are you required to file your own claims?
If so, what is the filing process? 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.

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

What benefits are available for the treatment of mental-health conditions and alcohol or chemical dependency? Which 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.

• What benefits are available for prescription drugs?
Is there a maintenance-drug program, including a mail-order pharmacy? Are benefits limited to only those drugs included on a formulary (list of preferred drugs)? Is there a mandatory generic-drug substitution requirement? Are dentists’ prescriptions covered? Which pharmacies are affiliated with the plan?

If an HMO will pay only for drugs on its formulary, you may be required to change to another drug if the one you are using is removed from the formulary in the future. Exceptions are possible upon an appeal from you or your physician.

• Who are the providers affiliated with the plan? Is 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.” When looking for a good doctor, 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? Will you need a referral to see a specialist?

Under a managed-care program, benefits may be denied or cut if you do not use a participating provider, or if you receive services from a specialist (even one in the plan) without a referral.

• What if you use a non-participating provider?
Will you receive any benefits at all under the plan?

• 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 much or how little service you get).

• Will 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, check the criteria that must be met to receive benefits. Your child may have to return home for needed medical care.

Finally, you may want to ask these questions:
Is medical case management available?
What services require prior authorization and what are the notification requirements? What are the penalties for non-compliance?
How can you appeal denial of benefits?

Choose now for 2001
Deadlines coming up for choosing benefits
November 17 —
• Deadline for enrolling in Health Care Spending Account (HCSAccount) program that lets you set aside up to $3,000 in pre-tax salary to pay for unreimbursed health-related expenses. For an enrollment kit, call 1-800-358-7202.

November 30 —
• Deadline for enrolling in Health Option Program (HOP) for 2001 that lets you earn three fewer days of sick leave in exchange for reducing your health-insurance premiums by up to $300.
• Deadline for changing your Pre-Tax Contribution Program (PTCP) status. The PTCP allows payroll deduction of your health-insurance premiums before taxes are taken out, which lowers your taxable income and gives you more spendable income.
• Deadline for enrollees in the PTCP who want to cancel their coverage or change from family to individual coverage without a “qualifying event.”
• Deadline for changing the federally qualified status of your domestic partner.