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HEALTH INSURANCE: OPEN ENROLLMENT

Go Ahead--Pick a Plan, Any Plan

Well, not just any plan. You've got to figure out what--and who--works out best for you and yours. Here are tips to help you wade through the information.

September 29, 1997|DAVID R. OLMOS | TIMES STAFF WRITER

Each autumn, packets loaded with spiffy health plan brochures and book-length lists of doctors and hospitals arrive at our homes or in our office mailboxes.

Officially, it's known as open enrollment--the once-yearly period in which people with employer-provided medical insurance can change health plans. (People 65 or older who are eligible for Medicare can change their medical benefit elections throughout the year.)

Open enrollment means open season for medical consumers as health insurers aim to entice us to remain with, or switch to, their plan.

The vast majority of people offered a choice of health plans will stay put with their current program. But that won't be an option this year for hundreds of thousands of Californians whose health plans were swallowed up in corporate mergers among some of the state's biggest HMOs.

Members of health plans that are merging will want to make sure that their favorite physicians offer the new plan.

If you're thinking about switching health plans, there is much to consider: cost, convenience, benefits, and which doctors and hospitals are available to you. It can be a daunting task.

While many of us won't spend the hours it can take to do detailed comparisons of plans, there is more help available than you might think.

Over the past few years, some organizations have begun publishing comparative data on hospitals, medical groups and health plans. Such efforts, while still in their infancy, are expected to grow.

Meanwhile, as you ponder your choice of health plans, here are a few questions to consider.

Question: What do I need to know about the different benefits health plans offer?

Answer: Ask your employer or the health plan for a copy of the plan's summary of benefits. Read it carefully. Questions you might ask include:

* Are there any limits for coverage for preexisting conditions?

* What is the plan's process for deciding which tests and treatments are covered and which aren't?

* Are certain services limited or excluded altogether, such as infertility treatments or in vitro fertilization?

* Does the plan offer mental health, vision or dental services and, if so, what are the restrictions on those benefits?

* What about chiropractic and other alternative health services?

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Q: What are some other factors to consider?

A: Health experts recommend that, in comparing plans, you pay special attention to benefits that are most important to you and your family. For example, does the plan allow direct access to obstetrician-gynecologist or pediatricians? Are medical clinics open on evenings or weekends? Are your family's favorite doctors in the plan?

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Q: What are the differences between HMOs, PPOs, POSs and indemnity plans?

A: There are numerous differences, but they basically come down to your freedom to choose doctors, benefits and costs. HMOs (health maintenance organizations) are the most restrictive plans and limit your choice of doctors and, generally, require you to get approval from a primary doctor before you receive services. HMOs boast that they also pay for more preventive health services than other types of health plans.

A less-restrictive type of HMO is the point-of-service plan, which allows you to see doctors outside the HMO's approved "network," although you'll have to pay deductibles and co-payments when you do so.

The preferred-provider organization (PPO) falls somewhere between an HMO and a traditional indemnity plan. In a PPO, you usually pay a small amount--say, $10 per office visit--if you see a doctor in the approved network. If you go to a doctor outside the network, you'll pay more. With traditional insurance, you can use virtually any doctor or hospital, but your out-of-pocket costs can be quite high.

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Q: What are some of the considerations when comparing the cost of various health plans?

A: You will want to compare the monthly premiums, deductibles (mostly for non-HMO plans) and co-payments (the amount you must kick in for doctor office visits or prescription drugs). With non-HMO plans, check to see if there is a limit on out-of-pocket costs or a lifetime limit on what the plan will pay for your medical care.

If you have a medical need requiring ongoing treatment, equipment or a prescription drug, for example, make sure it is covered by the plan and in what circumstances.

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Q: Are there any ways to compare the quality of health plans?

A: It's not easy. Besides talking with friends, doctors or your employee benefits department about the reputation of certain plans, there is a dearth of reliable information.

Find out if the health plan is accredited by the National Committee for Quality Assurance by checking out that organization's Web site at http://www.ncqa.org or call (800) 839-6487 for a free accreditation report by state. Be aware, however, that experts say that accreditation is no guarantee of a health plan's excellence.

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