2 Experts, 6 Scenarios, Some Sound Advice

While nearly half of Californians with medical insurance have little or no choice over their health care product, being informed about what insurance options you do have is integral to making the right choice.

“The biggest choice of plans is with the biggest employers,” says Tom Sher. An insurance broker, Sher participates in various health industry advisory councils, consults for many government agencies and runs Sher Co. Insurance Services in San Rafael. “Those with choices should look for the best mix of price and access,” he says.

This translates into weighing the amount of your payroll deduction and cost at the time of service against your choice of doctors, hospitals and special services.

The Times asked Sher and Jeanne Finberg, senior attorney, policy analyst and head of health group for Consumers Union--publishers of Consumer Reports--to look at six family profiles and offer their advice on what insurance plan would work best:

Example No. 1

Single, mid-20s, good health.

Sher:

“For the single man, generally the highest probability of using the medical system is as a result of an accident. He’ll want a plan that covers him for catastrophic losses.

“Young single women need to pay more attention to the women’s health services available within their choices. Does the plan cover contraceptives as well as women’s checkups?

“Most young singles pick a plan with a lower payroll deduction and higher cost at the time of service.”

Finberg:

“This individual is a good candidate for a managed care plan. Single healthy people tend to do well in HMOs because they are looking for routine care and the unlikely possibility of emergency care.

“If you have a regular physician, you’ll want to make sure your doctor is on the list for the plan you choose. Women should find out if they can use their gynecologist. Find out what hospital your physician is affiliated with.”

Example No. 2

Single parent, mid-30s, one child with chronic asthma.

Sher:

“An HMO makes the most sense here, but the parent will want to examine how the HMO deals with asthma. Will the asthmatic child be treated by an allergist or a family practice doctor? Do they have a good outreach program? With any chronic illness, you need to check out how your health insurance choice will handle your situation.

“If the one you liked initially doesn’t fill your needs, then ask the same question of another HMO. Don’t assume all HMOs are all the same.”

Finberg:

“Most single parents choose their health insurance based on income. An HMO will be the least costly, but this parent must know what services the plan offers asthmatics. Some plans have special services. Other plans may be a problem because you must get referral from the primary physician.

“Also important is how emergency room visits are handled. There’s the possibility you won’t get to use your chosen hospital, and how does the plan handle that. This person might want to choose ‘fee for service’ coverage if a managed care plan does not have a good program from asthmatics.”

Example No. 3

Married couple, mid-30s, three children younger than age 12, all in good health.

Sher:

“Well-child checkups and immunizations will have this family visiting the doctor’s office often.

“HMOs generally have no deductibles, so this might be their best bet. In general, HMOs offer preventive care for both adults and children for less than the cost of PPO programs. Remember, by belonging to an HMO you usually must see your primary doctor before consulting a specialist unless you purchase one of the newer special access programs.”

Finberg:

“With three children to raise, this family probably has to think about money. They might want to consider a managed care program to keep costs down. We’d recommend they also choose a ‘point of service’ plan, in which the patient usually uses the doctors within the system but in special cases is allowed access to doctors outside the health plan and pays a bit more at the time of service. In fact, we recommend this feature to everyone. In this case, a pediatrician will be the issue here. Does this family have access to the one they want?”

Example No. 4

Married couple, late 50s, no dependents, husband has history of heart disease.

Sher:

“If his heart condition is not complicated, say he had bypass surgery several years ago with no problems since and the couple is happy with their doctors, an HMO will cost this couple less and might be their best bet.

“However, if it’s an evolving condition, they might be interested in a plan with easier access to specialty care. The key issue again is choice of doctors. It might be tougher to get to a top specialist within an HMO, although it’s not uniformly tougher. A PPO will cost more in payroll deduction and more when you use it. But seeing a specialist will be easier.

“Another consideration is HMOs have educational programs that PPOs don’t. Programs for cardiovascular fitness, weight management or smoking cessation are usually arranged at the medical group sites of HMOs.”

Finberg:

“Financially, an HMO might be their choice, but studies have shown that elderly people don’t do as well in managed care. This couple is more likely to prefer a fee-for-service plan or an HMO with a point-of-service plan. Hospitals will be very important here. The couple should check out the emergency-room track record of their chosen hospital, also procedures and statistics concerning heart surgeries. They need to assess their costs because they can add up very quickly.”

Example No. 5

Married couple, 65, no dependents, wife has chronic illness requiring long-term care.

Sher:

“There are two broad alternatives here. Plans that supplement or coordinate with Medicare benefits and Medicare-HMOs. Medicare-HMOs may offer less choice of doctors than a regular HMO plan. While $5 doctor visits are seductive, this choice probably wouldn’t cover all her prescription drug expenses or out-of-network services she may need. Fee-for-service plans will have broader choices and fewer limits.”

Finberg:

“Medicare generally recommends that seniors use the fee-for-service option, which Medicare heavily subsidizes. Even though the patient pays more, it’s not much for what you get.

“Most insurance policies don’t cover long-term care. Neither does Medicare. There are rare situations in which HMOs will cover it.”

Example No. 6

Widowed female, mid-70s, good health.

Sher:

“A Medicare-HMO may be the best choice, as seniors tend to have less income and might lean toward spending less on insurance. Since she is healthy, the trade-off of choice versus cost may work best for her. Limits on pharmaceuticals could present a problem. Some HMOs may offer nonmedical benefits such as dental and vision coverage.”

Finberg:

“Studies show older women have trouble navigating the managed care system. I would suggest she stick with the fee-for-service program to be able to access the care she needs.”