Money Essentials

Which health insurance plan is right for you?

Choose the plan that gives you the services you're most likely to need at the lowest out-of-pocket cost.

If you get coverage through your job, your employer picks your insurance and you may or may not have very many choices. If you buy your own, you're in charge, but your choices are limited by the plans available to individual purchasers, as well as by how much you can afford to spend.

Unfortunately, there's no such thing as standard coverage. Details vary enormously from one plan to another. The best value is not necessarily the plan with the cheapest premium or the one with the most benefits. It's the plan that covers the health services you want and need for the lowest out-of-pocket expense . In essence, differences among plans come down to three intertwined elements: benefits, costs, and restrictions.

Benefits: Every insurance plan will cover you for doctor and hospital bills, with various limits, discussed below under "costs." Virtually everything else, including prescription drugs, glasses, psychotherapy and preventive care, such as immunizations and screenings, may or may not be covered, depending on the specific plan.

To figure out how well a plan suits your needs, first make a list of the health services you and your family normally use. For each plan, note the amount of coverage for each of those services - for instance, "100%," "80%," "not covered." Once you've got a handle on how fully each plan covers your health needs, you can evaluate cost differences.

Costs: If you don't use many medical services, your primary cost for indemnity coverage will be the premium. If you do use a lot of services, it will be hard to gauge your actual costs, since you must factor in the deductible, co-payments, and any excess charges or uncovered services.

In contrast, cost is easy to gauge with a true HMO - a managed-care plan with no out-of-network option. Once you've paid your premium, nearly everything will be covered and you'll be liable only for co-payments.

Estimating the cost of a managed-care plan with an out-of-network option is tricky, because your ultimate cost depends on whether you actually go out-of-network. If cost considerations make you lean toward a managed-care plan, read its literature thoroughly to decide whether you can live with the restrictions it imposes.

Restrictions: Generally speaking, a managed-care plan will limit your choice of providers and require you to get pre-approval for services. If your beloved pediatrician shuns HMOs or you have a difficult health problem, you may decide that you can't abide limits like these.

Keep in mind, however, that indemnity insurance also comes with limitations in the form of deductibles, co-payments and uncovered services. These financial roadblocks can inhibit freedom of choice as much as any managed-care bureaucracy.

Another worry about restrictions is that many consumers equate freedom of choice with medical quality. They're not entirely wrong. If you receive poor treatment in a managed-care plan, it's hard to vote with your feet.

However, they're not completely right, either. The quality of medical care varies considerably both in and out of managed care. In fact, the best managed-care plans offer quality advantages you won't get outside managed care, such as outreach for preventive services, heath-risk screening, and coordination of care.

Know your provider

Whether you choose indemnity insurance or managed care, it's wise to check up on your providers in advance. One way is via state insurance department websites. Florida, Maryland, Massachusetts, New York, and Rhode Island, for instance, post lists of local doctors who have been disciplined for poor patient care or, in some cases, criminal conduct. New York and New Jersey rate local hospitals and doctors on how well they care for cardiac patients. Florida, New Jersey, New York, Maryland, Texas, and Utah rate local managed-care plans.

Nationally, the Joint Commission on Accreditation of Health Organizations and the U.S. Department of Health and Human Services' Hospital Compare Tool are the major rating group for hospitals, the National Committee for Quality Assurance rates managed-care plans, and lists surveys and other data on selected health plans and health services.

If the insurance plan you prefer seems unaffordable, check the money-saving strategies in the next section to see if there's a way to reduce your costs.

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