If you dread your health insurance plan’s open enrollment period, with its fine print to read and new plans to ponder, Elizabeth Abbott can tell you why. “The reason it’s hard is that you know it’s important,” says Abbott, director of the California Office of the Patient Advocate (OPA). “This is a decision that has consequences for you and your family.”
You shouldn’t put this decision off until the last minute, and the OPA, which collects and reports on information about healthcare quality, has tools to help with your research.
The OPA’s 2015-16 California Health Care Quality Report Cards, released Oct. 8 and available at www.opa.ca.gov and as a smartphone app, rank more than 200 medical groups, 10 HMOs and six PPOs on measures that go beyond cost. The report cards look at whether HMOs and PPOs – and the medical groups they use to provide care to patients – do a good job of making sure that children are immunized on time, screening adults for health conditions such as cancer and diabetes and meeting other measures of quality care.
The clickable cards let you drill down to look at details, such as what percentage of a provider’s patients had a follow-up visit within seven days after being admitted to a hospital for mental illness, or how often doctors check to make sure kids are at a healthy weight. The information comes from a random sample of HMO and PPO members selected each year to have their records reviewed to determine if their care meets national standards for effective care and treatments.
A random sample of HMO and PPO members is also surveyed each year about their experience with the care and services offered by their health plans. Patients are asked about whether they can get appointments quickly, whether their claims are paid on time and whether doctors communicate well with them, among other things, and the results are shared in the OPA’s report cards.
These report cards and other tools in the OPA website’s Health Insurance Basics section are a great place to start, whether you’re looking for a new insurance plan or deciding whether to make changes to your existing coverage. But they won’t answer all your questions.
If you have a doctor, specialist, hospital or medical center you are happy with, for instance, you should find out whether they are part of the network in plans you are considering. Even if they are currently part of your plan’s network, check again during open enrollment because networks can change. If your plan drops your doctor, you could be hit with an out-of-network charge when you seek care.
If you or someone in your family is taking a particular medication or undergoing treatment for a chronic condition, you also need to know whether your plan will cover that care. And you should find out what type of after-hours care is covered, and whether the plan provides access to a 24-hour advice nurse.
Where can you find out?
You could start with a document called the Evidence of Coverage (EOC). This is the contract between you and your health insurance plan, and it details – in several pages of technical legal language – the services covered in your plan and what you are expected to pay for care.
If your plan’s EOC makes your eyes cross, don’t give up. At very least, carefully read the parts of the document covering any specific health conditions or concerns that apply to your family. And see if the provider offers a shortened version of the EOC. “Most plans have a much more consumer-friendly version on their website, and I would definitely look at that,” advises Abbott.
If you don’t find clear answers to your questions in the EOC or on the plan’s website, give the provider’s customer-service line a call. The OPA lists customer service phone numbers and hours for all of the plans in its quality report cards. “They generally, I have found, have been very good at answering specific questions,” Abbott says. “I think they are interested in your business, and I think they are interested in giving you good care. It’s in the plan’s best interest to keep you healthy.”
And it’s in your best interest to find the right plan for your family’s healthcare needs. “Being an informed consumer is a really important thing,” Abbott says. “This is one of the most important decisions you will make this year.”