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Insurance - Head Matters


4. Health Insurance

b. Choosing a health plan 

Your employer may provide a plan for you or you may buy one yourself.  Regardless, there are some questions you should ask yourself when considering a health insurance plan:

  1. How affordable is the entire cost of your and your family’s health care?
    1. What is the monthly premium I will have to pay?
    2. Should I try to insure most of my medical expenses or just the large ones?
    3. What deductibles will I have to pay out-of-pocket before insurance starts to reimburse me or cover the costs?
    4. After I have met my deductible, what percentage of my medical expenses are reimbursed?
    5. How much less am I reimbursed if I use doctors outside the insurance company’s network?
  2. Does the insurance plan cover the services I am likely to use?
    1. Are the doctors, hospitals, laboratories and other medical providers that I use in the insurance company’s network?
    2. If I want to use a doctor outside the network, will the plan permit it?
    3. How easily can I change primary-care physicians if I want to?
    4. Do I need to get permission before I see a medical specialist?
    5. What are the procedures for getting care and being reimbursed in an emergency situation, both at home or out of town?
    6. If I have a preexisting medical condition, something that I am aware of before I purchase insurance, will the plan cover it? Some plans do, while others don’t – it may also depend on the type of medical condition.
    7. If I have a chronic condition  such as asthma, cancer, AIDS or alcoholism, how will the plan treat it?
    8. Are the prescription medicines that I use covered by the plan?
    9. Does the plan reimburse alternative medical therapies such as acupuncture or chiropractic treatment?
    10. Does the plan cover the costs of delivering a baby?
  3. How can I determine the quality of an insurance plan?
    1. How have independent government and non-government organizations rated the plan? For example, the National Committee for Quality Assurance ( ) issues a Consumer Assessment of Health Plans (CAHPS) report for every medical plan and facility. 
    2. What kind of accreditation has the plan received from groups such as NCQA or the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) ( 
    3. How many patient complaints were filed against the plan last year and how many were upheld by state regulatory agencies like the state insurance commission or the state medical licensing board? 
    4. How many members drop out of the plan each year? State insurance departments keep track of “disenrollment rates.” 
    5. Do the doctors, pharmacies and other services in the plans offer convenient times and locations? 
    6. Does the plan pay for preventive health care such as diet and exercise advice, immunizations and health screenings? 
    7. What do my friends and colleagues say about their experiences with the plan? 
    8. What does my doctor say about his or her experience with the plan?
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  • Insurance Information Institute
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