How to Determine what Health Plan Option is best

Choosing the best health insurance package available to you is a stressful, anxiety-provoking chore. It’s hard to know how much health care you will need. It’s difficult to compare the costs and benefits of competing plans. But, your health and financial well-being is at stake, so you have to make a decision. But how?

A systematic approach may improve the quality of your final decision, and also reduce your anxiety during the process. Dividing this huge chore into bite-size pieces may make it easier to accomplish. The following nine-step can help you decide which choice is best for you.

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Although no-one can predict the future with certainty, history is the best available guide to estimating how much care you (and your family) will need in the upcoming plan year.

If you have a well-organized personal medical file, take it out and review it. Otherwise, gather all the information you can find. Gather all your prescription medicines. Go through old date books, highlighting medical appointments. Check your checkbook and credit card accounts for doctor and pharmacy bills. If necessary, call your doctor’s office, and ask if they could briefly review your medical file.

This data will give you an objective basis for decision-making. After collecting what you can, develop a list of your health care needs for a “typical” year, including:

A. Office visits to your primary physician, dentist, eye doctor and other specialists.

B. Generic and brand-name medications

C. Preexisting or chronic conditions, and special medical needs.

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Compare how each company does business, and what benefits their plans offer.

A. Can you go to any doctor you want, or only to those in a network? If your plan has a provider network, are your current doctors in it? Can you see out-of-network providers for non-emergencies? If so, how much extra does it cost? How easy is it to change doctors?

B. How do you obtain obtain care? Do you need to select a primary physician? If so, do you need a referral from your primary physician to see a specialist? Do you need to carry your own medical records to specialist appointments? Are dental and eye care covered?

C. What medications are available? Which drugs are on the plan formulary? (The formulary is the list of medications approved and covered by a plan.) How much do you pay for generic, brand-name, and non-formulary medications? Can you be required to take generic versions of drugs instead of brand-name?

D. Do you need a referral to get a blood test or an x-ray?

E. What hospitals can you go to? Do you need precertification before going to the hospital (except in emergencies)? How do you access to after-hours emergency care?

F.. Do you pay doctors large amounts up front, then submit claims for reimbursement? Or do you pay a flat fee for each visit? Are there lifetime limits on coverage?

G. How much do you pay in weekly or monthly premiums?. Are there any exclusions or limitations on coverage?

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Several websites that can help you through this process.

A. NCQA (National Committee for Quality Assurance), a well-respected, private, not-for-profit organization dedicated to assessing the quality of managed care plans, offers a Health Plan Report Card that rates hundreds of health plans on quality of service, and access to care. It can give answers to questions that are unavailable anywhere else, such as: Which plan will take better care of you if you get sick? Which plans check doctor’s credentials? You can create a customized report card for the plans you are considering. Go to:

B. U.S. News and World Report cosponsors a site on “America’s Best Health Plans” with NCQA that ranks over 550 commercial, Medicare and Medicaid plans based on clinical performance and customer satisfaction. Go to: s/index.html

C. AHRQ, the Agency for Healthcare Research and Quality (part of the federal Department of Health and Human Services) publishes a 36-page report, “Questions and answers about health insurance,” that explains the differences between plans and lists more helpful resources. You can find it at

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Only you can decide what is important to you in a health plan. Ask yourself questions like these:

A. Are there doctors you really want to stay with? Or could you just as easily change?

B. Do you need a generous medication benefit?

C. Do you hate getting referrals for specialist visits and lab tests, or don’t you mind?

D. Do you need the freedom of picking any doctor you choose, or could you settle for a smaller network at a lower price?

E. Could you deal with submitting claims whenever you see a doctor? Or would that make drive you crazy?

F Do you need to a high-deductible plan because you are enrolled in a health savings account?

G. How important is a plan’s reputation and quality control record, as reported on the web?

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Once you have a list of items that are most important to you in choosing a health plan, prioritize your list and decide some way to score it. Develop a score sheet to rate how well each plan meets your needs.You could give points from 1 to 10, or a simple “yes” or “no.”

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Now take out the detailed plan description from each insurance provider, and score each plan against the list of judging criteria on your score sheet. You may want to change how your score sheet works after scoring one or two plans. (If so, go back and score them again with the revised score sheet, to make sure every plan is judged on the same basis.)

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After you have scored each plan, compare them to each other and order them from best to worst. Eliminate any plans that cannot give you what you need.

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Now estimate how much each plan will cost. Start with the highest-ranked plans, and work your way down the list.

Don’t get hung up on any particular benefit that may cost more or less in this plan or that. The only important number is the annual bottom-line cost – the total amount paid for medical care during the plan year, including office fees, medications, premiums (include amounts withheld from your pay) and any other fees.
Now, get the annual estimate of health care needs developed in step 1, and the detailed plan descriptions provided by your employer or insurance broker, and any past medical bills that may be relevant to the coming year. Calculate the total amount each plan would cost for the amount and type of care specified in your estimate. Take into account:

A. Office visits (flat fee or percentage co-pay)

B. Extra fees and separate deductibles, if any, for out-of-network care.

C. separate deductibles for out-of-network care?

D. annual deductibles (if any)

E. Annual limit for out-of-pocket expenses (if any)

F. Costs for generic, brand-name, and non-formulary prescriptions.

G. Discounted mail-order pharmacy option (if any)

H. Charges for blood tests and x-rays cost

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You now know what each plan offers and what it is likely to cost you. Compare them to see which gives you the best trade-off of benefits and costs. Relying on your common sense, experience, and the results of this process, you should be able to choose the best plan for you. (It might be easier to repeatedly eliminate the worst plan until one is left, rather than trying to pick the best one right away.)

If you still can’t decide, delay your decision for a few days, if possible, but keep the subject in the back of your mind. Sometimes when you immerse yourself in a research project like this, you get a fresh perspective after standing back from it for a while.