It’s open enrollment again for health-care benefits, but don’t take anything
for granted this year and next. Coverage, consumer information and treatment
are changing faster than ever.
Closely read the health-plan literature and ask careful questions of your
benefits experts and co-workers. Your life might depend on it.
Let’s talk about what to look for in a health plan. As a patient, parent,
grandparent and former chief nurse executive at a large public hospital, I
have a few tips, gleaned from 38 years of experience with folks just like
You are not alone if you are bewildered in trying to navigate the
health-care system. Consider the stories of two fellow public employees:
David Brailer has a four-year-old son. Playground mishaps and childhood
illnesses make pediatrician visits inevitable. Brailer is mystified by his
health plan and its complex billing statements. “When I get an explanation
of benefits, I can’t figure out what happened or what I’m supposed to do,”
he told the New York Times earlier this summer.
Robert Kane has an elderly mother who is recovering from a stroke. He and
his sister “spent three frustrating years trying to organize care for our
mother” he told the Wall Street Journal in August.
Your two co-workers who are fighting with their health plans are leading
physicians who share your frustrations and fears:
Brailer is a Harvard-trained physician who serves as the White House senior
adviser on health information technology.
Kane is a practicing physician who specializes in the elderly, an author of
three health-policy books, and a university professor.
“If somebody who knows as much as I do and knows as many people as I do
couldn’t get the system to work,” Dr. Kane said, “what chance does anyone
That’s why you need to read the stuff, do some research, ask questions and
be an advocate for yourself and your family.
Use these 10 steps to help evaluate health-care benefit providers:
If you’re considering an HMO, see how it’s rated by the state Office of
Patient Advocate (OPA) on this handy, simple report card. Or you can look at
the Department of Managed Health Care’s consumer reports on PPOs and other
health plans. The California Department of Insurance also maintains a
consumer information resource about health insurance. All of this
information can be viewed on their respective Web sites.
Narrow your choices to two or three candidate plans. Be sure they are
accepted at your favorite hospital. Ask your co-workers about their
experiences. If you or a family member have a chronic condition–such as
diabetes, heart disease or asthma–find co-workers with the same conditions
and ask about their experiences. Don’t be shy.
Now you have personal stories and information from the plans and the
consumer guides. Write down all your questions. Get answers from the
benefits person in your department’s personnel or human resources units. Ask
until you get it.
Never feel dumb. About half of all Americans cannot understand most
health-care-benefit documents, according to several studies. OPA recommends
that insurers write documents at the sixth-grade level for quick and easy
comprehension. Most of the plan paperwork is written for college graduates.
Look for a plan with primary physicians to help you manage your visits and
treatment. For specific ailments, you often have to see a specialist after
your primary doctor. So find out the average waiting times to see
specialists. Be sure specialists are taking new patients and are not two
counties away. If you switch plans, do you get to keep your current
physicians and facilities?
Look for a plan that helps you and your family stay healthy. Is there
coverage for preventive care? Does it include immunizations, physicals,
screenings for cancer and other illnesses?
Do you or a family member have a chronic condition? See if the plan helps
you manage a chronic condition. Nurse case managers or others trained in
navigating the system are very helpful.
Does the plan cover any current prescription drugs, or would you have to
To take care of yourself, you need information about the costs and quality
of hospitals, clinics, outpatient surgery centers, physicians and other
health professionals. Insurers are increasingly offering comparative data
online. “Where’s the data?” is the next question, followed by, “When will it
be available?” By the way, a statewide hospital rating report card is due
out in November from the California Healthcare Foundation: