1: What Type of Plan Is It?
Find out if it is an indemnity health plan or a managed care system. With indemnity health plans, also known as fee-for-service plans, you pay a percentage of the medical costs, and the insurance company pays the remaining percentage. Typically, you are allowed to choose your own doctors.
With managed care -- meaning either a health maintenance organization (HMO) or a preferred provider organization (PPO) -- you have minimal out-of-pocket expenses. With an HMO, you or your employer pays a fixed monthly fee for health-care services, but you can only go to a doctor who is under contract with the HMO. Through a PPO, you or your employer gets a discount if you use physicians within the plan. You may go to a doctor outside the PPO system, but you'll pay more.
2: How Much Will I Have to Pay for Medical Care?
Find out the amount of the premium. Next, ask whether you will be charged a co-payment, a small flat fee, perhaps $10, charged for health care services.
Some plans have a deductible instead, an amount that you have to pay before the policy starts to cover any medical costs. Find out about this, and find out the percentage of costs that will be covered by the plan once you've met the deductible.
3: Will I Be Able to Use My Current Doctors?
Ask about any limits on choosing your doctors or hospitals. Ask for a list of the doctors and hospitals that are covered to decide if the plan is right for you.
4: What Benefits Are Included?
Ask what benefits are not covered by the plan, too.
5: Are Routine Examinations Covered?
Ask about mammograms, pap tests, immunizations and other routine check-ups.
6: Will I Have to Call My Doctor Before Going to the Emergency Room?
Some plans require you to contact your doctor within 24 hours of going to a hospital emergency room, or your costs won't be covered.
7: What Are the Plan's Restrictions on Pre-Existing Conditions?
If you or someone in your family has a chronic condition, the policy may not cover related medical costs for a period of months -- or ever. Ask for how long pre-existing conditions are excluded.
8: What Happens When I'm Away from Home?
If you need to go to the doctor while traveling, how much -- if any -- of the costs will the plan cover? How do you get reimbursed?
9: Is the Insurer Financially Stable?
Find out how long the company has been in business. You don't want to get a really good deal with low premiums, only to find out that you can only see a doctor during very limited hours.
10: How Does the Company Handle Disputes Over Claims?
All insurance plans have procedures for appealing denied claims. Many require that you take your dispute to an arbitrator, or an independent person who hears both sides and makes a decision about the claim. Ask what the company's average turn-around time is for resolving claim disputes.