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Clinton's Health Plan : Health Plan: A User's Guide : Health Coverage Checklist

September 26, 1993|KATHY M. KRISTOF

Choosing a health plan that's right for you and your family isn't easy. Here's a checklist of questions you should ask--of yourself, plan representatives and people already using the plan--when evaluating any health plan, regardless of whether the Clinton reform proposal is enacted:

Quality

* Does the plan have specialists skilled in treating problems that run in your family, such as heart disease, diabetes and high blood pressure?

* What kind of testing capabilities are available? Does the plan have access to an MRI? An ultrasound machine? If the test you need isn't available, would plan doctors schedule an outside test? Would you be required to undergo other, possibly less accurate, tests available in the plan before an outside referral is made?

* Do you have confidence in the plan's doctors? Are they are knowledgeable and interested enough in you to make sure that you're getting the most appropriate treatment? Can you choose a primary care doctor that has expertise or special interest in ailments that concern you? For instance, if you have serious allergies, can you choose as your primary care physician an allergist who attempts to ferret out the root of your problems rather than just treat the symptoms?

* Will your doctor take time to get to know you and your family? Is he or she willing to become familiar with your medical history?

* Are plan physicians willing to consider alternative treatments that better suit your beliefs about health? If, for instance, you desire a holistic approach to medicine, are the doctors willing to discuss alternatives to antibiotics?

Cost

* How much is the plan premium and how does that compare to other health plans you could buy?

* What are your co-payments and deductibles and how do those compare with other plans? If you have children who need frequent check-ups and vaccinations, does the plan have a separate--possibly lower--co-payment rate for so-called "well checks" and other preventive medicine?

* If you're considering a managed care plan such as an HMO, what happens when you want to go outside the plan? Will you be completely on your own, paying all your medical expenses out of pocket, or will the plan still reimburse part of your costs? Does the answer depend on why you went outside?

* What is your total financial risk if you encounter catastrophic illness or injuries? Are there caps on your annual or lifetime out-of-pocket expenses?

Access and Convenience

* Are there waiting periods or coverage exclusions for pre-existing conditions, and do you or any covered member of your family have such conditions? (The Clinton plan will make this question unnecessary because you cannot be denied coverage for pre-existing conditions.)

* Would your primary care physician--or pediatrician--be willing to answer phone calls when not on duty? If not, who would you turn to when you have a medical problem after hours?

* How long would it take to schedule an appointment? Can appointments be scheduled on the spur of the moment when you have a pressing ailment?

* How does the plan handle emergencies such as auto accidents, falls, real and apparent heart attacks? If you're far from a plan hospital, can you go to the nearest facility and expect to be reimbursed?

* If you're considering a managed care plan, how are physician referrals handled when you need a specialist? Are you ever allowed to self-refer when it's clear what your condition is--such as when you become pregnant? Or must you always see a primary care doctor first? How long do referrals take? Can they be rushed when you have a pressing problem?

* What would happen if your primary care doctor refuses to pass you on to a specialist? Is there a way to appeal, or are you stuck?

* How long would it take to get to your doctor's office--and is the commute time an important issue to you?

* How long would you have to wait in your doctor's office? Is the doctor consistently on time? Would you be told in advance--or at least the moment you check in--when the doctor is running 45 minutes late or more?

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