How Do I Choose an Individual Health Benefit Plan?

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Many consumers shop for a health benefit plan primarily based on the cost of premiums, but many other factors influence the value of a policy.  We encourage you to look beyond just the monthly premium and consider variables such as plan benefits, provider availability, cost-sharing, company information, consumer satisfaction, and plan quality when you compare plans.  In addition, if you are considering an HMO, you should review OPIC’s HMO publications.

 

We have developed a list of questions to help you make an informed purchasing decision.

 

1.  Does the plan cover the services I need?

 

All individual health benefit plans sold in Texas must include certain federal and state mandated benefits.  However, plans vary based on the additional benefits they provide.  Make sure you understand what each plan you consider covers.  Discuss any special health care needs with your agent and carefully review plan documents to find a plan that meets your needs.  

 

2.  Are the providers I need (or might need) available near me?

 

Provider networks differ by plan.  Some plans only offer narrow networks with limited provider options, which may make it difficult for you to get the care you need.  Review provider directories to learn more about each plan’s network.  You will want to consider how far you will need to travel for routine and specialist care.  You should also evaluate the availability of critical services like hospitals, emergency rooms, and urgent care centers. 

 

3.  Does my provider participate in the plan?

 

If you prefer to receive care from specific physicians or hospitals, review provider directories to verify the providers you use are in the plan’s network. 

 

4.  What are my cost-sharing responsibilities?

 

In addition to premiums, you will also pay copayments, coinsurance, and deductibles.  A copayment is a fixed amount you pay for services such as doctor’s visits and prescriptions.  Coinsurance is the percentage of the cost of a service you pay for services like lab tests and imaging.  A deductible is the yearly amount you must pay before your plan will contribute to the cost of most covered services.  Many plans have changed the way they structure cost-sharing responsibilities over the past several years, and some of these changes can be confusing.  Make sure you understand your out-of-pocket costs before signing a contract. 

 

5.  How do I research the companies I am considering?

 

Check the Texas Department of Insurance’s website at https://apps.tdi.state.tx.us/pcci/pcci_search.jsp to verify that the company is licensed, view its financial information, and see the number of complaints against it.

 

6.  Additional Questions to Consider When Selecting an HMO:

 

HMOs are popular offerings in the individual health benefit plan market.  OPIC compiles annual HMO publications to help you compare these products.

 

        a.  Are current members satisfied with the plan?

 

Current member satisfaction is a good indicator of an HMO’s level of service.  Comparing Texas HMOs is OPIC’s annual report card on HMO consumer satisfaction.  You can review this information to find out how current HMO consumers rate their satisfaction with their doctors, their access to care, and the administration for the HMOs you are considering. Comparing Texas HMOs is available at http://www.opic.texas.gov/health/comparing-texas-hmos

 

         b.  Do members receive quality care through the HMO’s network?

 

The Guide to Texas HMO Quality compares HMO performance on quality of care measuresYou can use this publication to evaluate HMOs based on your individual health needs.  For example, if you have young children, you may be interested in an HMO with high child immunization rates.  If you have diabetes, you may want to consider an HMO with successful metrics related to that disease.  You can also consider performance across all measures for a comprehensive picture of an HMO’s quality. The Guide to Texas HMO Quality is available at http://www.opic.texas.gov/health/guide-to-texas-hmo-quality

 

Checklist for Choosing an Individual Health Benefit Plan:

     1.  Confirm the plan covers the services you need.

     2.  Make sure the providers you need (or might need) are available close to you.

     3.  If you want to keep your doctor, verify that he or she participates in the plan.

     4.  Understand your cost-sharing responsibilities.

     5.  Research the companies on TDI’s website.

     6.  If you are considering an HMO, review OPIC’s publications for member satisfaction and quality of care information.

 

 

I joined OPIC as a staff attorney in 2011.  I specialize in life, health, and disability insurance law.  I know that consumers can find themselves frustrated with these insurance issues at very difficult times in their lives—during sickness, after an injury, and after the loss of a loved one.  I am grateful that I can utilize my expertise to educate and empower insurance consumers as they navigate these challenges.