Helping You Choose A Quality Health Plan

Selecting quality health care services for yourself, your family or a friend, requires special thought and attention. Knowing what to look for and what to ask will help you choose a health plan that provides quality care and best meets your needs. If you have only one health plan available to you, the following questions can help you better understand your health plan benefits.

Health plans may include health maintenance organizations (HMOs), independent practice associations (IPAs), managed care organizations (MCOs), preferred provider organizations (PPOs), and specialty service systems.

You may want to begin by talking with your doctor about each health plan available to you. Then ask the following questions to determine which health plan meets your needs.

Questions about coverage and fees

• Do the services and specialties provided by the health plan meet your specific medical needs and the needs of your dependents?

   

• Do you have a medical condition requiring specialized attention? The type of health plan you choose may depend upon your medical history and current medical condition.

   

• Does the health plan have a written description of its services and fees? Be sure you are familiar with what procedures are covered or excluded under the plan.

   

• Is it important to you that your health plan cover preventive services such as annual physicals and child immunizations?

   

• Is it important to you that your health plan cover behavioral health services?

   

• Will the health plan cover your expenses if you schedule a visit with a doctor or hospital that is outside the network?

   

• Will the health plan cover your expenses for emergency care outside the network?

   

• What are the plan's deductibles, co-payments or out-of-pocket costs?

   

Questions about access

• Are the health care facilities and doctors that provide care under the health plan conveniently located? Can you and your family get there easily for scheduled, as well as emergency medical care?

   

• If you do not already have a doctor, are the health plan's doctors that are near you accepting new patients?

   

• Does the health plan require paperwork for each claim you make?

   

• If paperwork is required, is it easy to understand and complete?

   

Questions about member rights

• Does the health plan explain your rights and responsibilities as a member of the plan?

   

• Does the health plan maintain confidentiality of member files? Ask how confidentiality is maintained and under what circumstances specific member information is released.

   

Questions about policies

• Does the health plan have rules guiding your doctor's discussions of treatment options? Some health plans limit the type of information that your doctor can share with you. It's important to know what type of information may be limited and under what circumstances.

   

• Does the health plan dictate standardized procedures for certain diseases or medical conditions?

   

• Does the health plan limit how many referrals a doctor can order in a year for specialists or expensive tests?

   

• Does the health plan cover second opinions?

   

• Are doctors paid a salary, or do they receive a flat amount per member per month?

   

• Does the health plan have a process for appeals and grievances if your doctor refuses to refer you to a specialist, or if the plan won't approve your doctor's recommended treatment?

   

Questions about quality

• Does the health plan ensure that its health care professionals are qualified to offer the services and procedures you need?

   

• Does the health plan have a quality improvement program?

   

• Does the health plan monitor the quality of care provided at each care facility?

   

• Does the health plan have a procedure for receiving and resolving complaints concerning the quality of care?

   

• Is the health plan accredited by a nationally recognized accrediting body, such as the Joint Commission? Joint Commission accreditation means the organization voluntarily sought accreditation and met national health and safety standards. And, the Joint Commission is the only health plan accreditor that also inspects the facilities where care is delivered.

   

To find out if the health plan you are considering is accredited by the Joint Commission, see Quality Check® on this website or at www.qualitycheck.org. Quality Check is a comprehensive guide to all Joint Commission accredited health care organizations and programs.

To report information or concerns about accredited organizations:

• Call or e-mail our Office of Quality Monitoring  at (800) 994-6610 or complaint@jcaho.org.  
• You can also fill out a Quality Incident Report form.