Resources

Every consumer has their own needs that must be considered when choosing their health care coverage. The following are some general questions that all consumers might want to consider when trying to assess whether an HMO or other managed care plan is the right choice for their needs.

Benefits

What’s covered and what’s not?

This is important for all consumers to ask, but especially if they anticipate a particular need (i.e. obstetrical care, special medicines, etc.)

Doctors

What doctors are in the plan?

With a growing number of doctors participating in at least one HMO, there is a good chance that the doctors a consumer is already using may participate in the plan. Consumers should ask their doctors—primary care and specialists—which plans they participate with.

Credentials

How many of the plan’s doctors are board certified in their specialty?

Consumers should ask the plans what percentage of the plan’s doctors are board certified or board eligible (preparing to take the exams). In general about 85% of doctors participating in HMOs are board certified in their area of practice, meaning they’ve passed special exams in their field of practice. This compares with a board certification rate of just 61% of all doctors nationwide.

Referral Process

What is the procedure for seeing specialists or when hospitalization is needed?

It is always good for consumers to know up front how they will be required to access special care, will they need a referral from a primary care provider, how is that obtained, is it good for a period of time or will they need to return to the primary care doctor each time before seeing a specialist.

Emergency Care

What happens if someone gets sick away from home, or needs to use an emergency room?

Health plans have policies about accessing care in the emergency room (most require a person to call their doctor first, unless it is life threatening and calling could endanger a life) and what to do when traveling out of the plan’s coverage area. The procedures are always spelled out in the member handbook, but a member service representative can also go over the procedures with the consumer.

Member Satisfaction

What do current members of the health plan think?

People should ask friends or colleagues if they are members of the plan and if they are happy. Consumers can also ask the health plan for the most recent members satisfaction survey.

Quality of Care

Does the plan have a “report card”?

All New York State HMOs collect data on certain care measures—how many children under the age of two are immunized, how many women receive regular Pap exams or mammograms. These measures, called HEDIS, which stands for Health Plan Employer Data and Information Set, have national standards with which the plan can compare its experience. Most plans have used this data to develop report cards that show how the plan is doing and are usually very eager to share this information with consumers.

Independent Review

Is the health plan accredited by the National Committee for Quality Assurance, or some other independent accrediting organization?

There are several independent organizations that are responsible for evaluating every aspect of a health plan’s operation—from the certification of the plan’s doctors and the quality of care delivered to members, to the plan’s organizational structure and financial security. Plans that go through these independent reviews do so voluntarily. The reviews are very rigorous and thorough. Consumers should ask if the health plan has undergone any review process (or is planning to) and what its accreditation status is.