How to choose a health plan that’s right for you

It’s easy to feel a little confused about where to start when choosing a health plan. Some people ask their friends, family or co-workers for advice. Knowing the right questions to ask can help you make an informed decision.

Q: How can I figure out which health plan is right for me?
A: First, consider how much coverage you need. Are you single, or do you have a family? Do you or a family member have a chronic condition? It’s important to look at the full range of services and copayments (or “copays”) you will spend out-of-pocket for doctors’ visits, surgery, hospital stays or other types of care. And it’s important to know whether your plan covers preventive services, prescription drugs, or other services such as dental and vision.

Q: What about cost?
A: The total cost of coverage is important. You need to understand how much you will pay for your coverage in monthly premiums, how much your employer contributes, and what your co-pay will be when you seek care. Is the annual deductible a dollar amount, or a percentage of the costs for services you receive?

Q: What are my options?
A: You can choose an HMO or a PPO health plan. HMOs and PPOs differ in a lot of ways,  but the biggest difference between them is how you access covered services and how much you will pay out-of-pocket for them, including any applicable deductibles.

With an HMO plan, you must live or work within the service area covered by the plan. You access all care from a medical group in the HMO provider network and designate a primary care physician or Personal Physician to coordinate all your healthcare needs. Check to see if your health plan offers a direct referral option to specialists within your medical group.

With a PPO plan, you can visit any licensed doctor, including specialists, without a referral. However, though a PPO plan might pay for services received outside the preferred network, you will pay more than if you had received care from a doctor within the network. Not all physicians accept both HMO and PPO plans. If you want to see particular doctors, make sure they accept the health plan you’re considering.

Consider these other questions when comparing health plans.

Does the plan help keep you well?

1. Cover preventive care visits?

2. Offer incentives to adopt healthy life style habits?

3. Offer easy access to health resources and life management tools tailored specifically to women, men, children, and seniors?

4. Offer discounts to services you use regularly?

Does the health plan keep your family covered and add value?

1. Offer coverage to families living apart and dependent college students living outside California?

2. Are your children’s pediatricians or specialists in the network?

3. Provide tools and resources to help your family save money on health care?

Does the health plan make it easy to do business with them?
1. Let you change doctors, order new ID cards, and view your claims history online?

2. Have dedicated calling centers to help you with claims and questions?

CalPERS members can call our Shield Helps support team 24 hours a day, seven days a week during Open Enrollment, September 14 through October 9 at (888) 678-SHIELD.