Choosing a Health Plan or Medical Group

In the past, consumers had one choice to makeótheir doctor. Now you need to choose not only your doctor, but also the health plan and medical group your doctor is in. Start by understanding your personal health situation and what is important to you.

THINK about your current and future needs. Some questions you should ask are:

• Do you or your family have special health care needs? Does the health plan cover what you need?
• Do you want to keep your current primary care doctor(s), specialists, or hospital?
• If you have a chronic health condition, will you have access to qualified specialists?
• If you are on a particular medication, is that drug covered by the health plan? If not, what is the plan's process for getting a drug that is not on the "formulary" (a list of drugs approved by the plan)?

UNDERSTAND what a health plan costs. Ask about the cost of the monthly premium, and also any co-payments, co-insurance, or deductibles you may need to pay.

COMPARE SERVICES offered by the health plans you are considering. Ask your employer, insurance broker, Medicare, or Medi-Cal for a comparison of services. You should also get printed material from each plan. If you have specific questions about prescription drug coverage, authorization procedures, or whether a particular specialist is in the plan, call the health plan. Make sure to ask if you will be limited to certain specialists or hospitals based on the medical group your primary care doctor is in.

If you want information about Medicare options such as choosing between original Medicare, HMOs, or Medicare supplemental policies ("Medigap"), the Health Insurance Counseling and Advocacy Program (HICAP) can help you understand your options. Call HICAP at 1-800-434-0222.

FIND RATINGS to see how well a health plan or medical group meets the needs of its members. There are several Report Cards that compare health plans and medical groups. They may include information about the following:

• Satisfaction and experiences reported by health plan and medical group members.
• Rates of preventive services provided to members.
• How well HMOs and their doctors treat chronic conditions and help members avoid illness and get the right care.
• Whether patients see specialists and get tests or treatments in a timely manner.

Some independent sources of health plan and medical group information are:

• The California State Office of the Patient Advocate (OPA) publishes an annual Quality of Care Report Card. To get current HMO and medical group ratings, as well as information on plan services in languages other than English, check out the OPA web site, www.opa.ca.gov/report_card or call 1-866-466-8900 to order the Report.
  
• The Pacific Business Group on Health (PBGH) is an independent, non-profit coalition of large companies that purchase health care coverage. PBGH publishes data on quality of care in health plans, medical groups, and hospitals. Information is available at the PBGH web site, www.healthscope.org.
  
• The California Public Employees Retirement System (CalPERS) purchases health benefits for state employees and other public employees. It publishes data on their contracted plans to compare how different plans rate in terms of member satisfaction and effectiveness of care. Check out the CalPERS web site, www.calpers.ca.gov or call 1-800-237-3345 to speak with an agent.

Medicare HMOs:

• Medicare + Choice plans are HMOs that contract with Medicare. To get information about the plans in your area, look at the "Medical Personal Plan Finder" link at the Medicare web site, www.medicare.gov or call 1-800-633-4227.
  
• Consumer Reports' "2003 Guide to California Medicare HMOs" is available at no cost at www.calmedicarehmos.org or may be ordered by calling 1-888-430-2423.

Health Rights Hotline counselors can help you understand the
resources available to you as you make choices about your health care.
Call 916-551-2100 or toll free 1-888-354-4474.
Check out our website: www.hrh.org