The chart that accompanied the article on choosing a health plan (Cover, Nov. 20) listed premium rates for 1991, not 1990 as labeled. Partners Health Plan is now known as Aetna Health Plans of the Mid-Atlantic. (Published 11/27/90)
It's time again to think about health insurance. It's time for federal employees, their families and retirees -- 11 million people nationwide -- to decide by Dec. 10 whether to stay with their health plan or pick a new one.
It will be time sometime during the coming year for almost everyone employed by a private company that provides health insurance to do just the same.
For the "feds," it's called open season -- a four-week period for people to review their health coverage and switch to another plan if they wish.
Oh, for the old days when an employer's health plan covered just about everything, when Blue Cross-Blue Shield cared for almost everyone and there were no hard choices to make.
No more. The world of health insurance is now a world of competing plans fighting for "market share" with glowing promises, while doing everything possible to combat ever-growing medical costs by limiting their benefits in one way or another.
Health insurance companies and consumers alike are the victims. The plans -- and employers -- are variously imposing increased monthly contributions for coverage, new deductibles (cash up front before a plan even triggers in) and new co-payments (cash out of pocket when you get care).
This is not to say there are no good plans, or that enrollees of Healthy-Wealthy-Gesundheit University-Ultra or whatever appealingly named plan you choose may not take good care of you in many an illness.
But in some situations it may not. Plans vary widely, and for feds and non-feds the choices can throw you for a loop.
Unless you spend some time thinking and investigating.
Some federal employees must pick a new plan this year. Five plans affecting Washington area workers are giving up the ghost.
For everyone else, the question is: stick or switch? Health insurance and health care experts say:
There are no perfect plans. If your plan has served you well, stick with it. If you have a good doctor -- and can see him or her only under your present plan -- you have a compelling reason to stand pat.
At least think about switching if you're dissatisfied with your present plan or your doctors. But investigate carefully or you could do worse.
Think about a change if your plan offers poor coverage for some personal condition or problem that another plan would cover better. Is there a new baby ahead? Possible or probable surgery? A chronic illness? A need for psychological counseling or treatment for drug or alcohol addiction? Older age or impending retirement?
Beyond this, you face two basic decisions.
With many plans, you must decide whether you want high option (meaning more expensive) or low option (usually called "standard") coverage. High option isn't always best. Weigh the coverage against the cost.
Then you must choose between two different kinds of coverage.
Traditional health insurance -- Blue Cross or some other -- either pays or reimburses you in whole or part for care by whatever doctors or hospitals you choose.
Traditional insurance plans sometimes offer the best coverage for mental health or addiction care.
An HMO (health maintenance organization) or some variant covers most of your care for a fixed monthly payment, with few added bills, but it limits your choice of care givers and hospitals.
There are HMOs that give all their care at their own clinics with their own staffs. There are others that use doctors in private offices. And there are various combinations of these, including plans where you are fully covered if you use "their" doctors or hospitals but pay extra for others.
Many of these HMO-type plans have similar names. The words "Health" and "Care" are especially common. So look carefully. Two plans that sound the same may be very different.
The best HMOs screen their doctors carefully, which means a high level of medical competence. HMOs can be especially economical for the elderly, the chronically ill or couples with young children who need frequent visits for checkups, shots and childhood illnesses.
HMOs under one roof can often provide one-stop care when you need tests or have to see more than one doctor or therapist. But your doctor or whatever primary doctor you see also becomes the "gatekeeper," who decides whether you may see a specialist.
HMOs -- unless they agree there's a special need -- may also hesitate to refer you to specialists outside the plan, whom they must pay. In today's world, this kind of "managed care" -- care that restricts your options -- is found in both traditional plans and HMO or HMO-like plans, to various degrees.
For example, the Office of Personnel Management -- overseer of federal employees' health plans -- has said that beginning Jan. 1 all plans -- whether traditional or an HMO -- must do two things. First, they must "pre-certify," meaning approve, all non-emergency hospital visits. (If you enter the hospital without approval, you will be hit with a $500 penalty.) Second, they must engage in "large-case management," meaning they must monitor all expensive continuing care and pay only for care deemed both appropriate and least costly.
In most plans of any kind, hospital visits must be approved in advance and the amount of time you spend in the hospital will be strictly limited. The plan will pay only for services and charges it considers "appropriate," and -- unless you ask beforehand -- you may not know what kind of extra bills you will be responsible for.
How to choose between plans?
Ask people you know about their plans and experiences. If you're interested in an HMO, visit a clinic run by the HMO and talk to some of the staff. Read each plan's literature to see what is and what isn't covered. If something is not mentioned, it may not be covered.
Ask questions. Ask:
How much will I have to pay? What are the premiums -- and the future deductibles and co-payments that I'll have to shell out?
Does the plan cover all physician services or only those it approves? Maternal and child care, including immunizations and checkups? Physical therapy? Any home care after an illness? What about prescription drugs? Any dental care? Eyeglasses? Mental health care? Drug or alcoholism treatment? Emergency care? An ambulance? Care out of town?
What -- specifically -- is not covered? What are the limits in days or number of visits placed on various services (such as physical therapy or addiction or mental care)?
What happens after I retire? Can I continue in the plan? Can I ever be canceled?
If you're considering an HMO or similar plan, ask:
Can I choose and stay with my own doctor? How do I find out about your doctors? (Some HMOs provide lists of their physicians, with their qualifications.)
Where will I get my care? Is the office or clinic convenient? What are the hours? What if I want to see a specialist? What hospitals can my family and I use? How easy -- or hard -- is it to get the plan on the phone?
To survive in any plan -- or any part of the American health system or non-system -- try hard to find and hang on to a good doctor, one who listens, one who cares, one who doesn't stand at the door poised to leave immediately on entering the room. Ask friends, co-workers -- and health plan nurses and other employees -- about doctors.
Don't wait until you're sick to doctor-shop. Good HMOs encourage you to get a periodic physical examination (though you may have to wait some weeks for an appointment). This is a good way to get to know a doctor.
Don't hesitate to change doctors if dissatisfied. But don't be too hasty either. That hurried cold fish sometimes turns out to be a skilled and dedicated human being when the chips are down.
Whatever plan you choose, learn how it works. Study the literature, learn what the plan will and won't do or pay for, learn all your rights. In some plans, you may find yourself seeing a nurse-specialist or "N-P" rather than a doctor for some services. You may find you like this. And you can always say, "I want to see a doctor."
Learn how and when to use the phone to reach a plan or doctor. Don't call on Monday morning or Friday afternoon, or on days after holidays or during lunch times unless absolutely necessary. Phone well ahead for future appointments. Before going to a typically busy doctor's office or clinic, phone ahead to say, "Will there be a long wait today? Should I come later -- or tomorrow?"
And be a good patient. Listen to the doctor and other care givers. Take notes or ask the doctor to write down something complicated. Don't be afraid to ask all the questions on your mind. Make a list of them in advance. And if you can't be there for a scheduled appointment, call to cancel.
Learn where to go in an emergency, day or night, weekends or holidays. Telephone ahead that you have an emergency -- or just go, and if possible have someone call to say you're on your way.
There is almost no medical care without problems. You must learn who to complain to and how to complain if you get poor service or are denied care, or if your treatment isn't going well or you think you've been charged too much.
The "how" to complain may just mean talking to a doctor or staff member. If that doesn't work, the "how" may have to mean a more formal complaint. Every good plan should have a procedure that will assure you a prompt response.
But if a doctor or staff or HMO or insurance carrier pays no attention -- or fails to give you a reasonable hearing and answer -- you may be the person who has to say: "This year, I have to change my health plan."
Federal employees and retirees must decide by Dec. 10 at the latest whether to change health plans. Two booklets describe and rate the many federal plans:
The annual -- this is its 12th year -- "Checkbook's Guide to 1991 Health Insurance Plans for Federal Employes" by Walton Francis and the editors of Washington Consumers' Checkbook magazine, $5.95 on newsstands or $7.45 (including first-class postage), Checkbook Insurance Guide, 806 15th St. NW, Suite 925, Washington, D.C. 20005. (202-347-7283).
"Open Season Guide" by Gordon F. Brown, $10 (including first-class postage) from Employee Benefits Review, 715 8th St. SE, Washington, D.C. 20003. (202-546-3394). Also in some bookstores.