Merritt Personal Lines Manual: Questions to Answer Before Your Client Joins an HMO
You should answer a few questions for your client before advising him or her to join an HMO. Here's a list of the most important questions (and you should be able to answer most of these about traditional health plans, too):
- What exactly does the plan cover? Some services, such as mental health treatment, drug rehabilitation or dental care, may not be included at all. While you can't possibly predict all of your health care needs, find out if the treatments you think you'll need are covered. Also, find out if treatments that are considered experimental or non-traditional, are permissible under your plan and, if you're interested, if alternative or holistic treatments are covered.
- What will it really cost? Don't just look at the monthly premiums. Consider the overall costs, including co-payments and deductibles. Some plans offer a reasonable limit on the total you will pay each year. Others place a lifetime limit on what the company will pay, which you can reach if you have one major health problem.
- Do you have a choice of doctors? Be sure you have some flexibility. Also be sure at least a few local hospitals and pharmacies are covered under the plan.
- Is there a utilization review process? In some plans, you cannot switch doctors or see a specialist without authorization. What happens if you don't like the doctor you choose? This can delay or deny care.
- Who decides what is considered "medically necessary"? Is it the insurance company or the doctor who decides?
- How are pre-existing conditions handled? If you have a pre-existing condition, such as high blood pressure, you may be liable for all costs relating to the illness. Know when and if your insurance pays for illnesses you may have.
- What is the relationship between the doctor and the plan? If your doctor receives a set fee per patient (capitation) or receives a bonus for minimizing costs (incentives), your healthcare could get shortchanged. The physician may be reluctant to order tests or referrals under these situations. Gag clauses can prevent doctors from revealing their compensation or discussing treatment options not covered by the plan.
- Does the plan have a grievance procedure? What if something goes wrong? Can you appeal? Be sure to talk with someone who is authorized to answer your questions, like the plan administrator - and keep good records. Who regulates HMOs in your state and what's the procedure to lodge a complaint if you think you're being treated unfairly?
