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Shopping Around for Coverage

How Does Your Health Plan Measure Up?

The key to navigating the system is understanding how it works. And sometimes tenacity doesn't hurt.


WASHINGTON — It's that time of year again--employers call it "open enrollment"--when many people are given a chance to select or switch health plans. Today, Health arms you with information, tips and resources to help you make the best choice for you and your family.


Illness is never a pleasant experience.

But far more unpleasant is the moment when you find out that your medical insurance will not cover either a treatment that your doctor recommends or one that you believe you need.

No matter your health plan, there may come a time when you have to fight to get medical care. And the last thing you need to be doing when you are sick is fighting with your insurer or doctor.

For this emerging world of managed health care, you need a new set of operating instructions. This article is a quick guide to help you head off problems before they occur, and to help you get the medical care you need when disputes arise.

The recommendations here are ones on which health care experts across the spectrum of opinion--HMO representatives, consumer advocates, insurance regulators and others--generally agree.

The most important thing to keep in mind is that you are not alone. There are government officials, consumer groups and staff at your health plan who can help you maneuver through the bureaucracy.

Two rules to keep in mind from the start, according to many experts: Understand how your plan works and call for help if you think you have been unfairly denied care.

"Most insurers operate in a reputable fashion, but there are also insurers who have questionable claim denials," said Kathleen Sebelius, the insurance commissioner of Kansas and chair of the health committee for the National Assn. of Insurance Commissioners.

"While we cannot make a company pay a claim, we typically can help expedite the process and help consumers figure out if the claim denial was legitimate," she said.

New Mindset

For better or worse, for most of the past century patients went to doctors, did what the doctor told them to do, and insurers generally paid the bill. That set of relationships has changed drastically in California and elsewhere during the past 10 years.

Today, the doctor, the medical group and the health plan are tied together through financial arrangements and incentives to reduce the cost of care. Many considerations influence their decisions, including keeping the lid on costs, keeping profits at a certain level and making sure the patient gets the necessary treatment--neither more nor less.

With traditional insurance, the doctor was virtually free to order whatever tests or procedures deemed necessary, and the insurer paid as long as the service was covered by your policy. With managed care plans, your doctor often must get prior approval from the medical group or health plan before going ahead with certain treatments. If the insurer refuses to authorize a procedure, test or treatment and you still want it, you have to pay for it out-of-pocket. But the option of paying for medical care yourself is not realistic when it involves an expensive surgery or other costly test.

"All of a sudden there is someone out there saying, 'No.' It may be your doctor, your medical group, your health plan or your employer, who is no longer offering the same scope of benefits they were offering 10 years ago," said Peter Lee, director of the consumer protection program at the Center For Health Care Rights, a Los Angeles patient advocacy group.

All this means that if you want to get the best possible medical care, you need to be an activist. That does not guarantee that you will get the result you want, but it will take you in the right direction.

"To make things go right, you have to take action," said Susan Pisano, spokeswoman for the American Assn. of Health Plans, which represents roughly 1,000 managed care plans nationwide.

"You have to put time into advocating for yourself," says Larry Leavitt, a senior health policy analyst at the Kaiser Family Foundation, a nonprofit health care group in Palo Alto.

And especially when things go wrong, it is crucial to take action. In a survey of 2,500 consumer complaints in Sacramento, roughly one in four people reported a serious problem with their health plan. Half of those people contacted their doctor or plan and got it resolved.

"But a third of people who had problems did nothing about them because they thought it wouldn't do any good," said Lee, whose organization helped with the study.

Before Disaster Strikes

If your car needed repairs, you would go to the garage with a list of problems: The engine is smoking; the brakes are soft and there's a loud rattling noise. The mechanic would inspect the car, discuss the likely problems and recommend repairs.

You may spend more time thinking about that meeting with the mechanic than you do thinking about your health insurance or your most recent doctor's visit.

Here are four things you can do to lessen the likelihood of a problem with your plan.

Know what your insurance policy covers.

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