Choosing Health Insurance

i 3 Table of Contents

Sourced from “Your Guide to Choosing Quality Health Care” (5last updated July 2007) report published by the U.S. Department of Health and Human Services, Agency for Healthcare Research & Quality.

Today there are more health plans to choose from than ever before. Not everyone has a choice. But if you do, this section can help you choose health insurance quote and a plan that offers the best quality for you and your family.

The quality of health plans varies widely. In 1997, a study published by the National Committee for Quality Assurance (5NCQA) showed differences in the ways managed care organizations provide access to care, keep people healthy, treat illness, deliver high-quality service, and satisfy patients. For example, studies show that treating heart attack patients with beta blocker drugs saves lives. The NCQA found that in some health plans, most heart attack patients got beta blockers. In other health plans, only one in three did.

Research shows that Americans say that quality is the most important thing they think about when choosing a health plan. But research also shows that few people understand their options well enough to make an informed choice.

Quick Check for Quality

Look for a plan that:

  • Has been rated highly by its members on the things that are important to you.
  • Does a good job of helping people stay well and get better.
  • Is accredited, if that is important to you.
  • Has the doctors and hospitals you want or need.
  • Provides the benefits you need.
  • Provides services where and when you need them.
  • Meets your budget.

Your Health Plan Affects Many Things

  • Who will care for you (5doctors and other health care providers), and how much choice you will have.
  • What kind of care you will receive (5for example, which preventive services are covered?).
  • Where you will receive your care (5which hospitals, for example).
  • When you will receive your care (5will you receive it when you need it?).
  • How you will be cared for (5the quality of care you receive).
  • How much you will pay.

What Are Your Choices?

The two major types of health plans are “fee-for-service” and “managed care.” Managed care plans can go by many names, including:

  • Health Maintenance Organization (5HMO).
  • Preferred Provider Organization (5PPO).
  • Individual Practice Association (5IPA).
  • Point of Service (5POS) plan.

But different groups do not always define these names the same way.

Do not be confused by whether the plan is a “fee-for-service” plan, or whether the plan is one of the many kinds of managed care plans. What you need to understand is not the plan’s label, but the characteristics of the plan. Research shows that it is important to understand your options and how they affect your choice of providers and services, costs, and quality of care.

How to Make Decisions Based on Quality

The next section lists several questions you may want to consider when choosing a health plan. These questions are based on research about what consumers want to know when choosing health plans. Under each question you will find more information to help you choose the plan that is right for you. You also will find a way to compare the health plans you are looking at. Here’s how:

Please enter the name of each plan you want to compare on a separate line (5Plan A, B, and C).

Plan A: ________________________________
Plan B: ________________________________
Plan C: ________________________________
Read the questions. Which are most important to you in choosing a health plan?

Do members rate the plan highly on things that are important to me?
Does the plan provide preventive services to help keep people well?
Does it do a good job of helping them get better when they are sick?
Is the plan accredited?
Does the plan have the doctors and hospitals I want or need?
Does the plan provide the benefits I need?
Do the doctors, pharmacies, and other services in the plan have convenient times and locations?
Does the plan meet my budget?
Read and think about the information under each question. Then ask yourself the question. If the answer is “yes” for a plan, check the box next to its name.

Of course, the answers to these questions may not be as simple as “yes” or “no.” Still, these questions should help you to think about and compare your health plan choices.

Do this for all the questions you have chosen.

Do members rate the plan highly on things that are important to me?

Before you join a plan, it is hard to know what kind of care you will get. One way to find out is to learn what members of the plan say about it. This kind of information is called consumer ratings or consumer satisfaction information.

More and more states, businesses, health plans, Medicare, and even the Federal Government’s personnel office are starting to use a survey called Consumer Assessment of Health Plans (5CAHPS®). It tells them what members think of the plans they are in. CAHPS® was designed by national experts in health care quality, under a project funded by the Agency for Health Care Policy and Research.

Also, NCQA has added CAHPS® survey questions to its own member satisfaction survey. The NCQA survey is part of its performance measurement program, called HEDIS (5Health Plan Employer Data and Information Set).

The information from the CAHPS® surveys is summarized in reports to help you compare health plans and decide which one is best for you. Here are examples of the kind of information you will find in a report that is based on CAHPS® survey questions:

Do members get the health services they need? Without long waits?
How easy is it for members to get a doctor they are happy with?
How easy is it to see a specialist?
Do doctors in the plan listen carefully?
Do they explain things well?
Are office staff polite and helpful?
Is the health plan’s customer service good at giving information and helping with problems?
Do members have too many forms to fill out?
How do members rate the care from the doctors and other health care providers in the plan? How do they rate their plan overall?
Find out where the survey information came from. Is it CAHPS®, HEDIS, or another source? Are you satisfied that it is a reliable source? Who collected the data?
How can you find consumer ratings? Ask your employer, Medicare or Medicaid office, or the health plan if a CAHPS® or HEDIS survey report is available. If not, ask if there are other consumer ratings.

You also may want to check your phone book for your State’s department of health, or the insurance commissioner’s office. For more help in finding your State health insurance contact, write or call the National Association of Insurance Commissioners at Executive Headquarters, 2301 McGee, Suite 800, Kansas City, MO 64108-2604; telephone 816-842-3600 or, if busy 816-374-7175. The information also is available at its Web site: :// .

Does the plan provide preventive services to help keep people well?

Does it do a good job of helping them get better when they are sick?

The Health Plan Employer Data and Information Set (5HEDIS) uses various types of quality measures. The HEDIS clinical performance measures are based on information such as members’ medical records. These measures help to compare how well plans prevent and treat illness. For example, one HEDIS measure looks at how many adult smokers or recent quitters were advised to quit by a health professional in the plan. Another looks at whether 2-year-olds are up to date on recommended shots. Some other HEDIS measures look at breast cancer screening, prenatal care, and at eye exams to prevent blindness in people with diabetes.

States, employers, health plans, and groups like the California-based Pacific Business Group on Health use HEDIS performance measures to prepare reports for consumers. These reports are known as performance reports, report cards, or various other names. They also may include HEDIS member satisfaction ratings or other consumer ratings.

To find out if there is performance measure information available on the plans you are looking at, ask your employer, Medicare or Medicaid office, or the health plan. Or, call your State department of health or the insurance commissioner’s office.

When you read the report, check to see where the measures came from. Are you satisfied that it is a reliable source?

Is the plan accredited?

Many health plans choose to be reviewed and accredited (5given a “seal of approval”). Contact the following organizations to find out if the plans you are looking at are accredited, or find out from the plans.

The National Committee for Quality Assurance (5NCQA) evaluates and rates managed care plans using more than 50 standards. The standards focus on efforts to continuously improve quality of care; doctors’ credentials (5training, licensing, and other background information); members’ rights and responsibilities; preventive health services; and whether appropriate health care services are provided.

Visit NCQA’s Web site at :// to generate a report card on one of hundreds of health plans. You can also call 1-888-275-7585 or 1-800-839-6487 to ask for the following information:

Accreditation Status List, which lists all the health plans NCQA has reviewed. (5No charge)
Accreditation Summary Report for any health plan reviewed since July 1995. (5$3 per report by mail)
The Joint Commission on Accreditation of Healthcare Organizations (5JCAHO) evaluates and accredits all types of health care organizations. JCAHO standards focus on patient-related areas it views as most closely related to improving health outcomes. The standards cover: rights, responsibilities, and ethics; continuity of care; education and communication; health promotion and disease prevention; leadership; management of personnel and health information; and continuous quality improvement.

Call 630-792-5800 to ask for information on specific accredited managed care or other organizations. Or visit the JCAHO Web site: :// Information on accredited organizations is free of charge.

The American Accreditation HealthCare Commission/Utilization Review Accreditation Commission (5URAC) develops accreditation standards and programs for managed care. Its Network Standards address five general areas: network management, utilization management (5checking to see that health care resources are used appropriately), quality management, credentialing, and member participation and protection.

Call (5202) 216-9010 for information on accredited organizations. Or, for a free list of accredited organizations, visit the Commission/URAC’s Web site at ://

Does the plan have the doctors and hospitals I want or need?

Here are some questions to think about:

Are you happy with your current doctors?

Call their offices to find out which plans they are in. You may be able to choose a plan that will allow you to keep seeing those doctors without paying extra.

Do you want to make sure the plan includes the kinds of doctors you will want to see?

Call the plans you are looking at to get a list of their doctors and other providers. Or, ask your employer’s benefits manager.

And remember, the hospital you go to often depends on the plan you are in and where your doctor has privileges. If going to a certain hospital is very important to you, keep that in mind when choosing a plan.

Does the plan provide the benefits I need?

Which health care services are most important to you and your family? Do the plans you are comparing provide these services? Check the health plan materials from your employer or the plans. Or, ask your employer’s benefits manager or the plan’s customer service office. For services that are provided by each plan, check the boxes next to those services that you want or need. There are extra spaces at the end of the list in which to add other services.

Are These Services Covered?

Plan A

Plan B

Plan C

Cancer screening (5colorectal cancer tests, mammograms, Pap smears, etc.)

[_] [_] [_]
Cholesterol screening[_] [_] [_]
Immunizations (5shots)[_] [_] [_]
Prenatal care[_] [_] [_]
Well-baby care[_] [_] [_]
Care for a pre-existing condition
(5one you have before joining the plan)[_] [_] [_]
Diabetes supplies[_] [_] [_]
Dental exams/treatments[_] [_] [_]
Eye exams/glasses/contact lenses[_] [_] [_]
Hearing exams/hearing aids[_] [_] [_]
Outpatient prescription medicines[_] [_] [_]
Medical equipment for use at home[_] [_] [_]
Mental health services[_] [_] [_]
Physical therapy[_] [_] [_]
Hospice care[_] [_] [_]
Counseling to stop smoking[_] [_] [_]
Drug and alcohol counseling[_] [_] [_]
Alternative treatments (5such as acupuncture or chiropractic services)[_] [_] [_]
Home health care[_] [_] [_]
Adult day care[_] [_] [_]
Nursing home care[_] [_] [_]
___________________________________[_] [_] [_]
___________________________________[_] [_] [_]
___________________________________[_] [_] [_]
Do the doctors, pharmacies, and other services in the plan have convenient times and locations?


Here are some questions you may want to call the plan to find out:

Are the services close enough to home or work?
Are they on convenient routes for public transportation?
Is parking available?
Are offices open in the evenings and on weekends?
Does the plan meet my budget?
Use the health plan materials from your employer or the plans to answer these questions and enter the information on the line provided under each plan.


Plan A

Plan B

Plan C

How much will the premium cost me each month?




If there is a deductible, how much will I have to pay before the plan starts to pay for medical care?
For prescription medicines?




How much will I have to pay (5co-payment) each time I use a service?
Doctor visit
Hospital visit




How much more will I need to pay if I go outside the health plan’s network of doctors, hospitals, and other providers to get services?