A health plan's accreditation status will tell you how well it measures up in terms of delivering its coverage. But if the insurance company offering the plan is in the midst of a merger, or if it's not doing well financially, chances are it's not going to be able to deliver services as well as it should. Be sure to do some research about the insurance company: Is there talk of a merger with another company? If so, how will it affect you and your employees? Are the company's financial statements in order?
A number of ratings services provide information about the financial health of insurance companies. Once you've got the goods on the company, make sure you understand the ins and outs of the health plan you're buying. Often when plans are presented, they will show you a summary of benefits. Behind that summary there are details of coverage. Employers often won't receive those details until they've already purchased the plan, unless they ask for it up front.
For example, two plans may offer prescription coverage with a $5 co-payment. But one plan may only pay for certain drugs — what's called a closed formulary — while the other will pay for all prescriptions.
On any coverage, a health plan will impose limits, and it's important to find out what those limits are before you buy. The Employer Quality Partnership — an organization that helps employers find health plans — lists questions you should ask of a health plan before you make your decision:
How much paperwork? If you're joining an HMO, chances are that the paperwork will be pretty minimal. But PPOs and traditional indemnity plans may require your employees to file claim forms for reimbursement. How quick is the turnaround time for claims and appeals?
Emergency standards: Find out whether your health plan follows the "any prudent layperson" standard to pay for emergency room services, or whether you have to get prior approval in order to be covered for a visit.
Out-of-pocket expenses: Know the plan's deductibles, co-payments, and maximum annual and lifetime payouts. Ask if there are different out-of-pocket expenses for different kinds of care, such as mental health services.
Member satisfaction: Find out from your state insurance department or the Better Business Bureau if any formal complaints have been filed against the plan. Ask the plan itself for the results of its latest member-satisfaction survey.
Grievance and appeals process: Federal law requires that health plans set up a formal process for members to appeal claim denials and file other grievances. These will vary from company to company. Find out whether your plan's appeals process is internal or external and whether there is third-party arbitration for difficult problems. Understand how the appeals process works and the average amount of time it takes to settle a problem.
The fine print: Be aware of the circumstances under which a plan will and will not cover some services. Ask specifically about limitations and exclusions on experimental procedures, transplants, infertility treatments, mental health coverage, drug therapies, and durable medical equipment.
References: Ask for the names of other companies who use the plan and give them a call. Ask also for the names of one or two similar-sized companies that have left the plan in the past year and call them to find out why.
Related Article:
List of Free Online Health Insurance Quote:
UK Travel Insurance