Kids and Health Care: Choosing the Right Plan
Look for a good pediatrician first, then work on how to make your health insurance fit your doctor. But, for some people, that strategy requires too much work and too much time. They prefer to choose a health plan first -- and then pick a pediatrician from those already enrolled.
Fair enough.
If you're going to choose a plan first and then look for a doctor, you need to consider some of the kinds of service and coverage your family will need. And this is especially important if someone in your family has a chronic or serious health condition.
Indemnity and managed care plans differ in their choice of providers, out-of-pocket costs for covered services and how bills are paid. Refer to Chapters 3 and 4 for more information on these two types of plans.
The plan that is "best" for your neighbor may not be the "best" plan for you and your family.
In addition to basic benefits, you might want to find out if the plan you are considering covers:
- physical exams and health screenings;
- care by specialists;
- hospitalization and emergency care;
- prescription drugs;
- vision care; and
- dental services.
The Department of Health and Human Services Agency for Health Care Policy and Research (AHCPR) also recommends looking into how a plan handles the following:
- care and counseling for mental health;
- services for drug and alcohol abuse;
- OB/GYN care and family planning services;
- care for chronic (long-term) diseases, conditions or disabilities;
- physical therapy and other rehabilitative care;
- home health, nursing home and hospice care;
- chiropractic or alternative health care, such as acupuncture; and
- experimental treatments.
If health education and preventive care benefits are important to you and your family, you might want to ask about services such as, shots for children, breast exams, Pap smears or other programs to counsel kids who need it.
In order to get a true idea of what your costs will be under each plan, you need to look at how much you will pay for your premium and other costs. You can't possibly know what your health care needs for the coming year will be, but you can guess what services you and your family might need. To figure out what the total costs to you and your family would be for services under each plan, it makes sense to ask the following questions:
- Are there deductibles you pay before the insurance begins to cover your costs?
- After you have met your deductible, what portion of your costs are paid by the plan?
- Does this amount vary by the type of service, doctor or health facility used?
- Are there copayments you must pay for certain services, such as doctor visits?
- If you use doctors outside a plan's network, how much more will you pay?
- If a plan does not cover certain services or care that you think you will need, how much will you have to pay?
- Are there any limits to how much you must pay in case of major illness?
- Is there a limit on how much the plan will pay for your care in a year or over a lifetime?
Some people choose a deductible in the thousands of dollars -- making their coverage, in essence, a catastrophic insurance policy. In this case, you'd absorb all the everyday costs of medical care, from doctor visits to prescriptions. But, if you got seriously ill, you'd be covered. If you are single and healthy, this could wind up saving you money.
For most people, a deductible in the $100 to $250 range is easiest to live with. But look into other deductibles, too. If your family has been healthy for a number of years, you may want to switch to a deductible of $500 or $1,000. You'll notice a sizable reduction in premiums. (Just remember that you'll have to pay your own way until you satisfy the deductible.)
Investigate what the insurance company considers usual, reasonable and customary charges, if at all possible. The charges a company considers normal for a particular medical procedure in a specific geographic area are the maximum it will pay. If the charges are higher, you'll be stuck paying the difference.
Another way you can save money on your premiums is by paying them annually. Find out how much the service fee is for monthly payments and ask whether there's a discount for prepayment.
Even if you don't get to choose the health plan yourself (for example, your employer may select the plan for your company), you still need to understand what kind of protection your health plan provides.
The more you learn, the easier it will be to decide what fits your personal needs and budget.
