How to Choose a Health Plan

Why Choose Loma Linda

We are a full service health system providing the state-of-the-art in emergency, urgent, primary and specialty care. Here is a partial list of our facilities:

With all the healthcare plans available today, choosing the right one for you and your family can be both confusing and difficult. You probably have a lot of questions and concerns about the important decisions you are facing. This guide will help you make those tough choices by showing you how to select the right healthcare plan for you.

Being prepared and knowing the right questions to ask are the first steps toward finding the right healthcare plan and physician for you and your family. We hope this information will help to simplify this complicated process.

  • For a referral of a Loma Linda University Medical Center-affiliated physician, please call 1-877-558-6248.
  • If you would like more information about Loma Linda University Medical Center's Health System, call 1-877-LLUMC-4U.

If you are concerned about the healthcare that you and your family are receiving, you will be happy to know that Loma Linda University Medical Center's Health System has been caring for the needs of over four generations of families like yours. Since our opening more than 80 years ago, we have served our community with devotion, compassion, and the best care available.

Health Care Models

Let's start by defining and comparing the most common health-care models. There is a wide variety of health plans offered today with new variations being introduced regularly. The following definitions will help you understand the differences between the basic models.

Indemnity

The basic role of an Indemnity Plan (also called "Fee-for-Service") is to process and pay medical bills, not to regulate or manage health-care decisions. This traditional insurance model allows you to choose care from any physician, any specialist, and any hospital without limitations on visits. There is no need for pre-authorization to obtain services. Instead, you decide which services to buy, and when and where to buy them.

The freedom of choice and convenience of an indemnity plan comes at a higher price than other health plans. Out-of-pocket costs include a deductible, coinsurance, and any other costs not covered by your insurance. After the deductible is met, the insurance will typically pay 80% of all charges deemed "customary and reasonable".

Health Maintenance Organizations (HMOs)

At the other end of the health-care spectrum are Health Maintenance Organizations (HMOs) or managed care plans. HMOs are designed to manage and maintain their members' health care. With an HMO, you can only go to doctors, specialists and hospitals that contract with your health-care plan. HMOs require that you select a "primary care physician" (PCP), the doctor who will coordinate ALL of your health services. For instance, when accessing specialty care, a referral from your PCP is usually required..

With an HMO, there are no deductibles to pay and co-payments are small. These fixed fees, typically due upon receipt of services, vary but are often between $5 and $15. There are several common models of HMOs.

The following is an outline of the different HMO models:

Staff Model HMO

Staff Model HMOs typically own and operate health centers or clinics. The doctors and other medical professionals are salaried employees. On-site services usually include pharmacy, laboratory, and x-ray among others. Some staff model HMOs own and operate their own hospitals, while others have contracts with a limited number of community hospitals. Any medical treatment must be obtained at the HMO facilities for it to be covered.

Group Model HMO

Group Model HMOs contract with independent groups of physicians to provide care. However, instead of employing the doctors and paying them salaries like the staff model HMO, the group model HMO negotiates a contract with the group of physicians to provide services for a fixed amount per patient.

Network/Independent Physician Association Model HMO

Network/Independent Physician Association Model HMOs are organizations made up of private practice physicians who sign contracts to provide care to HMO members for a fixed amount per member.

Although doctors and hospitals are the actual caregivers, HMOs influence the way doctors and hospitals provide care for you. Managed health care not only processes and pays for your health care, it also monitors how and what care is provided.

Preferred Provider Organizations

Preferred Provider Organizations (PPOs) are a network of physicians and hospitals that agree to provide care to patients at a discounted rate. This arrangement is sometimes called "discounted fee for service". In a PPO, you select a primary care physician who usually must refer you to specialists and hospitals within the network for that care to be covered to the fullest extent. By using these preferred providers, your out-of-pocket expenses are reduced, although you still pay a deductible and co-payment. With most PPOs, the insurance company will pay if you go to a provider not in the network, but at a lower percentage, which drives up your out-of-pocket expenses.

Exclusive Provider Organization

An Exclusive Provider Organization (EPO) typically consists of a group of physicians, a small number of hospitals, and other providers who contract with an insurer or directly with an employer to provide services at a discounted rate. This arrangement is similar to a PPO, however, enrollees must receive their health services only from the EPO providers; out-of-network services are not covered.

Point-of-Service Plans

A newer variation of the HMO model (no deductibles and small co-payments), the point of service (POS) option allows an HMO member to get care from doctors or hospitals outside the HMO network and still have a portion of the costs covered. People who choose the POS option pay a higher cost, usually in the form of higher premiums or higher co-payments for non-network care, or some combination of the two. Though the costs can be substantial for going out of the network, some people prefer the POS option because it offers greater flexibility and choice.

Selecting the Right Health Care Plan

After you understand the basic health-care models, it is important for you to assess your needs before deciding on a plan. Consider three key factors when choosing your health-care plan: coverage, quality, and cost. For each of these factors you will need to research and compare. This means making phone calls, reading brochures, asking questions, and most importantly, evaluating the services you and your family are most likely to use.

Coverage

Coverage will vary from plan to plan. Read over the information provided by the healthcare plan CAREFULLY. If anything is unclear or if you think that the plan does not match all your needs, call the company's customer service center and ask ALL your questions. This may take some time, but in the long run you will benefit from thorough exploration of your options.

The following list of questions will help you assess what type of coverage you need for you and your family:

  • Are you and your family basically healthy, requiring only routine checkups and minor medical attention?
  • Does anyone in your family have a chronic condition that requires regular attention and/or the care of a specialist?
  • Does anyone in your family have what would be considered a "pre-existing condition"? What does the plan consider a "pre-existing condition"?
  • Are you planning on expanding your family in the next year?

With the answers to these questions, look closely at the benefits package, the costs associated with it, the process through which care is accessed, and what restrictions the plan has on who delivers the services.

  • Is your physician or your child's pediatrician included in the plan?
  • How does the health plan and its providers network?
  • In the event of a serious illness or emergency, are the very best services in the community accessible?

Quality

When looking for quality, you really need to do some investigating. You may find that two health plans provide the same coverage at the same cost, but one plan is considered to provide better quality care to its members.

Here are some examples of quality questions:

  • How is the plan ranked by Consumer Reports?
  • What is the reputation of the plan you are considering?
  • Is the plan accredited by the National Committee for Quality Assurance (NCQA)?
  • What are the credentials of its doctors, specialists and facilities?
  • What type of preventative health services are provided? (Services to look for include: Childhood Immunization, Breast Cancer Screening, Cervical Cancer Screening, Prenatal Care, Cholesterol Screening, and Diabetic Retinal Exam.)
  • How are health services monitored?
  • How closely are medical records monitored for appropriate care?
  • Does the plan report a high level of member satisfaction?
  • What percentages of members file grievances?
  • What is the disenrollment rate?

Cost

All of these questions should be answered to your satisfaction before you consider the cost. After deciding which services and features are most important to you and your family, you can begin comparing the costs of various models and plans.

In addition to the quality and coverage offered, the cost of health-care plans will also depend on where you live, the amount of money your company provides for your health insurance, and the package of benefits your company has negotiated for its employees.

Choosing Your Doctor

Selecting a new health plan often means selecting a new doctor. Finding the right physician is essential to your satisfaction with whatever health-care plan you choose. Except in rare circumstances, once you select a plan and a primary care physician, most companies will not let you change until the next open enrollment period. As with your choice of health plans, the more informed you are when choosing your doctor, the happier you will be with your decision.

The Primary Care Physician

Most health plans require that you select one doctor from its network to serve as your main or primary care physician (PCP). These doctors offer comprehensive medical care and also have different specialties such as family practice, internal medicine, and pediatrics. Some plans even have OB/GYN (obstetrics/gynecology) doctors as primary care physicians. Having a primary care doctor will help ensure that all your medical records are in one place, your treatment will have continuity, and you will have someone who knows your medical history when referring you to specialists.

Open Enrollment Period

A time during which subscribers in a health benefit program have an opportunity to re-enroll or select an alternate health plan being offered to them, usually without evidence of insurability or waiting periods.

Common Questions About Selecting A Primary Care Physician

Q: How do I know which doctors are available to me?

A: Just ask for a copy of the most recent provider directory from your health plan or participating physician group to find a doctor in your area.

Q: Which hospitals can my doctor admit me to?

A: Most doctors are affiliated with certain hospitals. If there is a hospital you prefer, check to see if your doctor works with that facility. Your health plan provider directory should list this information.

Q: Which kind of primary care doctor will best meet my special medical needs?

A: An advantage of primary care doctors is their ability to provide care for a broad range of patients. At the same time, their practices may have special areas of emphasis, so it is important to find out if their background meets your particular needs.

Family Practice doctors (Family Physicians) offer general family health care for all ages. They may be a good choice for someone wanting one doctor who can care for the whole family.

Internal Medicine doctors (Internists) provide medical care to adults and adolescents. They are especially effective in treating chronic conditions such as hypertension and diabetes.

OB/GYN doctors specialize in obstetrics and gynecology. They have training in women's reproductive issues from childbirth to menopause. (Not all plans offer OB/GYN doctors as primary care physicians.)

Pediatric doctors (Pediatricians) specialize in children's health care and have training in child development from infancy through adolescence.

Q: Does my doctor have access to programs to help me improve my lifestyle?

A: Today, most larger health-care organizations emphasize wellness programs that teach you how to eat well, exercise, stop smoking, and screen for early warning signs of illnesses. Ask if your doctor and hospital are affiliated with this kind of program.

Here are some additional questions to consider when making your decision:

  • Do you wish to see a doctor in a traditional private practice setting or one in a health center with lab, X-ray, and other services on site?
  • Do you want one PCP for the whole family or have all your family's doctors in the same location?
  • How long does it normally take to get an appointment for routine care?
  • How long does it take to get an appointment when you are ill, but not in an emergency situation?
  • If you choose a physician group, are you able to see the same PCP each time you schedule an appointment?
  • If you require hospitalization, does your PCP admit you and manage your care?
  • Who covers for the physician during vacations?
  • How accessible is the physician in emergency situations?

Helpful Hints

  • Do not assume anything about your coverage. Each plan has its own benefits and its own exclusions, limitations, and reductions. For instance, if your current plan covers chiropractors under its preventative care package, do not assume that another plan will cover chiropractic care as well. Find out the specifics, not just the generalities of the coverage.
     
  • If you want to continue an existing relationship with a certain physician, specialist and/or facility, make sure that they are affiliated with the plan you are considering.
     
  • It is important to remember that your relationship with your current doctor may change if you choose a different model. For instance, if you switch from a PPO to an HMO, there may be significant differences in the way you access care, if you continue with the same doctor. Talk to your doctor in advance if you are considering such a change.
     
  • Find out if the healthcare plan has a quality assurance department. These departments are designed to monitor customer service and they may be able to answer many of these questions.
     
  • Ask your health plan if you can change doctors later on if you do not like the one you've selected. Or if you find a doctor you like who is not available through your current health plan, you may even decide to change health plans.
     
  • When selecting a physician, ask to see his or her credentials. Where was the physician educated? Is the physician board certified? What is his or her specialty? Does he or she have a history of malpractice?
     
  • Keep in mind that when you choose your primary care physician, your choice will often determine what specific group of doctors, specialists, and medical facilities to which you will have access. It is important to know where and with whom your doctor practices. Before selecting your physician, ask about the network of healthcare you are also selecting.
     
  • Most physicians are very busy people, but many are willing to make 10 or 15 minute appointments for prospective patients to interview them. Since communication is fundamental to a good physician-patient relationship, these interviews can be very valuable in helping you select the physician who will provide your healthcare.