Three Things Patients Should Know Before Buying A Health Plan

By Julie Appleby
Kaiser Health News

Consumers shopping for coverage in new online markets for health insurance will be able to see what plans are offered in their area, how much they will cost per month, what their annual deductibles  are and whether their families might qualify for federal subsidies or Medicaid.

But they should consider at least several other factors before making their decisions, which may take a little effort to ferret out.

1. Is my doctor or hospital in the plan?

For many consumers, this is one of the most important considerations, although it is not always easy to find out.  It’s especially important to check for those shopping for coverage in the new marketplaces because some insurers have created smaller networks of doctors and hospitals to keep premiums lower.

A first glance at the websites may not tell consumers the breadth of a particular plan’s network of doctors and hospitals. But most of the sites will include links to insurers’ provider directories.  Massachusetts’ website, for instance, describes insurers as either having a broad network or a more limited one. And in Nevada, the website allows shoppers to type in a doctor’s name to find all the plans in which that physician participates, says Robert Krughoff, president of Consumers’ Checkbook, a nonprofit organization that rates health care providers.

Because provider directories have not always been up to date or accurate, advocates suggest that shoppers double-check by calling their providers to make sure they are participating in that particular  plan. “If you are making a choice based on that, then you should certainly check” with your provider, Krughoff  stressed.

2. What drugs will the plan cover and how much might I pay for them?

Unlike the Medicare prescription drug program website, consumers shopping for health insurance through the new markets generally cannot enter the drugs they take to find out which plans cover them. But the websites are expected to include links to insurers’ sites, where that information should be available.

In addition, the health law requires insurers to provide consumers with a “summary of benefits and coverage” which includes detailed information about the policy’s annual deductible as well as how much it charges consumers for doctor visits, hospital care and prescription drugs, including co-payments for generic, brand-name and specialty drugs.  The health law limits overall out-of-pocket costs to no more than $6,350 for an individual, or $12,700 for a family per year.  Those benefit summaries will be availablewhen people are “shopping for coverage, enrolling in coverage, at each new plan year, and within seven business days of requesting a copy from their health insurance issuer or group health plan,” according to the Obama administration.  That information is important because policies may vary widely in how much consumers are on the hook for similar services, such as hospitalization, emergency room use, maternity care or drug costs,  said policy analyst Lynn Quincy at Consumers Union, publisher of Consumer Reports. The open enrollment period under the health law extends until the end of March, although consumers who want coverage to begin Jan. 1 need to enroll and pay no later than mid-December.

3. How do the insurers compare on quality and customer satisfaction?

In most states, consumers will see little or no data on quality or satisfaction this fall. That’s partly because the federal health law does not require the marketplaces to post quality information about participating plans for two years.  But it’s also because the policies are all new, so regulators don’t have a track record to measure.  Still, a few states, including Massachusetts, will include some measures of quality for this enrollment year.  Massachusetts notes how many “stars” each plan gets from the National Committee for Quality Assurance (NCQA), a rating agency. States that choose to include quality ratings on their websites this fall will rely on overall data about an insurance carrier, such as what percentage of its policyholders get recommended cancer screenings, rather than narrower data from a specific type of policy the insurer offers.  Consumers looking for more information about specific insurers can checkConsumer Reports, which links to data from the NCQA.   They can also look at U.S. News & World Report, which has developed its own ranking of health plans.

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Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.