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A Road Map to Choosing an HMO Insurance: Consumers are demanding more information about health plans. Here's a guide to some of the questions you may want to ask.


Marvelyn Foster is stretched so thin some months that she orders only half a prescription or goes without her asthma medicine altogether because she doesn't have the cash to pay up front, as her insurer requires.

When she chooses a new health plan this month, a decision thousands of people face at this time of year, she'll look for one that doesn't require her to mail in prescription receipts for reimbursement.

"I don't make that much money," the 44-year-old government clerk explains.

Ms. Foster, the mother of two boys, has figured out that low cost isn't always the best reason to choose a health plan. She is among a growing number of consumers who are studying their options carefully to find a health plan that suits their needs, instead of looking at just the bottom line.

As more and more Marylanders make the jump from traditional insurance to health maintenance organizations and other managed care programs, they and their employers are becoming pickier about what they buy.

Selecting the best coverage starts with knowing how managed care plans work, and then asking the right questions. Your choice may depend on factors ranging from how much a plan pays for preventive care to whether you mind flying to a hospital in Cleveland if you need a liver transplant.

Increasingly, private sector employees are expected to move into managed care, which is less costly than traditional insurance, and both insurers and big companies are working hard to promote this option.

Insurance companies such as Cigna, which once confined their message to the back of Forbes magazine, are spending tens of millions of dollars to lure consumers with ads in newspapers and on radio and TV.

Big companies also are encouraging employees to try managed care by helping them judge the quality of plans available. Blue-chips such as IBM are surveying employees to find the best medical plans and providing financial incentives for switching to them.

American Express has ranked health plans for three years based on its employees' reviews, and saw a huge shift from low-ranked plans into top-ranked ones.

In this area, the biggest user satisfaction survey of health insurance plans is done by the federal government's Office of Personnel Management. Your plan may differ, but this survey will tell you what federal employees think of plans offered by the insurers you are considering. A guide to the federal plans is published by Consumers' Checkbook in Washington and is on newsstands now. The paperback, which is priced at $8.95, also can be ordered by calling (800) 475-7283.

With relatively little information available, cost is still the biggest factor people consider, says Bob Davis, executive director of the Maryland Health Care Coalition Inc. As more people choose managed care, that is expected to change.

"In the last year or two years, there's been an absolute mushrooming of demand for managed care plans to furnish more information," Baltimore Gas and Electric benefits manager Elaine Johnston says. "This has become a big issue among managed care plans. The questions are coming from the purchaser and the consumer. Both are saying, 'Hey, tell us more.' "

The utility hopes to begin surveying employees this year for their opinions on the plans.

This year for the first time, BGE is giving employees a work sheet on how to choose a health maintenance organization. When HMOs were introduced in 1988, BGE simply told employees what they were and left it up to the HMO to market itself, says Ms. Johnston.

Minimum standards

But since 1991, when an "avalanche" of people began moving into managed care, the utility decided it needed to do more. It also tells its 8,000 employees which HMOs meet minimum industry standards, and has told the plans that don't they must obtain the stamp of approval from national accrediting groups by 1997.

At its simplest, managed care means that a health insurance card no longer gives the bearer carte blanche to buy medical care. Instead, patients are directed to a specific set of doctors, hospitals, laboratories, even drug stores that give the best deal to the insurer -- in terms of cost, quality service or both.

None of this much matters if you are healthy. How a plan works when you are sick is what consumers need to know. To start, it helps to know the basic forms of managed care:

* The HMO: The most restrictive type of coverage. Subscribers choose a primary care doctor in the group, who acts as a gatekeeper and controls what services a patient may obtain. The consumer is limited to the doctors, hospitals or other services associated with the HMO. Some HMOs such as the Columbia Medical Plan or Kaiser Permanente have their own staffs and offices, but others rely on doctors in private practice and contract separately with hospitals or other health care providers for items ranging from heart surgery to colonoscopies.

* Point of Service HMO. Members have the same primary care gatekeeper as above, except that they can buy health care outside the HMO if they are willing to pay a bigger part of the bill. Extra fees for this so-called "opt-out" feature vary from insurer to insurer, but some insurers may require you to pay more of the bill for a single service than they do.

* Preferred provider network. This is one of the least-restrictive managed care products. There is no gatekeeper, and subscribers can choose doctors and other services outside the network, often without penalty. Read the plan rules carefully, however, to make sure you understand what's permitted.

Perhaps the most common way of choosing a health plan is to find out whether your family doctor is a member. While this is a valid consideration, there are many issues to consider, among them that family doctors don't handle complicated medical problems or life-threatening illnesses.

Insurance questions

Here are some questions you should be asking:

* What kinds of catastrophic illnesses are covered? Liver transplants? Bone marrow transplants?

* How fast can you get to the top specialists and hospitals in your region? Are they even part of your plan? How much extra would you have to pay to use them in the event of an emergency?

* For catastrophic illnesses, such as a liver transplant, would the plan send you to Pittsburgh or to Johns Hopkins or the University of Maryland? There are pros and cons to any of these. The key is to ask the plan what quality factors it considers in choosing a center.

* Does the plan use sub-contractors for services? Blue Cross HMO's, for example, have contracted with the University of Maryland to perform all serious heart operations. That's an advantage if your cardiologist works there, but not if you want to continue seeing a doctor at Sinai. Other services often subcontracted are laboratories, mental health care and home health equipment.

* Does the plan offer preventive care at no extra cost? The average family could spend $700 to $2,000 a year on shots and office visits for babies and sick children.

* How convenient are the plan's doctors and hospitals to your home or work, how long is the waiting time in the office, and how easy is it to get your medical questions answered? These could be critical factors if a family member has a chronic illness.

* How many doctors does the plan have, how often can you change doctors, and how easy is it to switch?

* How many of the plan's doctors are actually accepting new patients? On some insurer's lists, as many as 40 percent of the doctors aren't, says Tracey Bahl, vice president of Cigna Health Care's MidAtlantic division.

* How many of the plan's doctors are board-certified in their field? Does the plan inspect doctors' credentials itself? Mr. Bahl suggests choosing a plan that does.

* How are doctors paid? If part of the doctors' salaries is tied to meeting financial targets, as is the case at many HMOs, they have an incentive to provide less care.

* If you're unhappy with your care, what is the formal grievance procedure?

Consumers are finding that they have to make compromises. Families with adolescents can find an HMO that covers braces, but they might not be able to choose the orthodontist who does the work.

For Ms. Foster, the government worker and mother of two boys, the priority is a better prescription plan, mostly for a son who suffers from seizures.

She is reading a mountain of literature put out by Blue Cross, Cigna and HealthPlus to find the policy that covers the monthly $65 for his anti-seizure drug Tegritol -- a cheaper generic doesn't work -- as well as the biggest chunk of the cost of ambulances that sometimes takes him to the hospital.

RF "There's always a deduction," she says, "but you try to limit it."

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