arent the only measure of cost
for annual health plan check up
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 dont
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.
Its 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 plans 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
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
What benefits are available for
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
Who are the providers affiliated with the
plan? Is there an adequate number of providers? How many
of the plans physicians are board-certified or
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
Does the plan restrict your ability to use providers of
your choice? Will you need a referral to see a
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
Will you receive any benefits at all under the plan?
How will your doctors reimbursement
affect your care?
Does the plan penalize your doctor financially if you
need frequent visits, referrals, or expensive tests and
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
plans 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 HMOs 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
How can you appeal denial of benefits?
now for 2001
Deadlines coming up for choosing benefits
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
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
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.