Selecting an Individual Health Plan

Choosing an individual or family health care plan is a decision that needs to be discussed and researched thoroughly. It is not to be taken lightly and several key components need to be established beforehand.

What area do you reside in? There are various companies that cover only certain regions and some that are countrywide. First you need to check what companies cover your zipcode.

Are you interested in an HMO or PPO plan. An HMO is a health maintenance organization while a PPO is a preferred provider organization. With HMOs you see a primary care physician (PCP) that you choose from either a group, (PMG) known as a primary medical group or the IPA, which is the Independent Provider.

PPOs have set fees and are within a provider network where you can change your Doctor at any time. You would choose a Doctor for each Specialty you need a Physician for.

With an HMO you will need a referral to a Specialist. When searching providers it is important to note whether they send speedy referrals or if they go through a system that could take two weeks or longer. You will also need to determine what type of Doctor you want for your Primary Care Physician within an HMO network. It will be helpful to look into where these Doctors send their patients for lab work, x-rays and Mammograms. Is this all within the same medical building, a Hospital nearby or dispersed throughout the city.

The choices range from Internal Medicine, Family Practice, Pediatrics, Obstetrics/Gynecology or General Practice If someone in the household has a skin condition and/or asthma and allergies you need to look for the specialists they would refer you to and note where they are located and what age group they specialize in.

If you are in the child bearing years consider an Ob/Gyn or if the children are older a Family Practice might be more suitable. Check with the plan and see if you can enroll members of the family with different Doctors and still be affiliated with the same Hospital. In this instance one parent might need Internal Medicine, another Ob/Gyn with the children in Pediatrics where they are all with Independent Drs or associated with the same group.

Pre-existing conditions could mean less choices to make or larger monthly fees. Prescription plans are part of the Health Insurance plan, so look into whether they only cover generic drugs and what the co-payment may be and the limits for one year on medication. Try to obtain a preapproved drug list and a list of authorized pharmacies.

Do you have a child or adult that regularly sees a Therapist, like Physical, Occupational or Speech. With an HMO they will need to get a referral to see these professionals and only so many visits will be approved before another referral or renewal is allowed or authorized. Some Doctors or groups may need progress reports to make sure the therapy is benefitting the Insured.

As someone who suffers with eczema and asthma I really do not like having to make an appointment to see my primary care physician to then get a referral to see the Dermatologist. There have been times that the PCP has given me prescriptions for my skin related condition, eczema and they do the asthma products. I have complained in the past when they refused to give me another refill on my asthma spray making me go to their office during holiday breaks with two children on the Autism Spectrum. At these times I choose to buy over the counter remedies for speedier relief and less stress. This is definetly a consideration when choosing an HMO and then the specialty you choose for the Primary Care Physician.

For the plan you are considering you need to check the local Hospitals and what the incurred cost, if any, would be for emergency room care and ambulance service. What is the deductible for hospital stays and are any of the Hospitals considered a teaching Hospital. Check to make sure the plan under consideration does not only provide County Hospitals.

Contact the medical group for a provider directory, check their hours, what are the languages they serve and are they accepting new patients? How long is the process should your child need to see an Ear/Nose Specialist? What is their scheduling like, does the Doctor visit patients in the Hospital before seeing patients, do they overbook, is there a month waiting list for an appointment and how do they handle emergencies?

If you become pregnant will you have a midwife or an MD? Can you choose someone specifically from the group for the delivery? What is the dismissal procedure after having a baby, do you stay 12, 24 or 48 hours after delivery? Do they perform circumcisions as part of the well care or is that an additional charge done in Hospital or as outpatient care?

Take a tour of the Hospital affiliated with your intended Health Care Plan, check the nursery area, children's ward and cafeteria. Inquire into visiting hours and look at the emergency room. Ask if they have any staff that assist with breastfeeding for new Moms.

Another thought is if the parent can stay overnight should a child have to be Hospitalized. This was allowed at both Hospitals my children have been admitted in.

The cost should be something you can handle each month or quarter, depending on which plan you choose for yourself and your family. Call up agents and ask for paperwork to read over. Look through all the paperwork before someone comes into your house to try to sell you a plan. Will you need to have any physical tests taken before signing up for the health plan. How long is the underwriting and review process?

It is important to know the cost associated, what are the Physician options and which Hospitals are contracted. Do online research of the Doctors and Hospitals. Find out if they have been sued for malpractice, check their Credentials.