Its that time of year again, complete with
all the sights and sounds of the season. That must be jolly old Saint Nick struggling with
his big bag of toys down the chimney.
Of course, you also have to know what you want out of a
plan to make a good decision. You may have strong opinions about whether you want a single
doctor making referral decisions for you, or you may have to give it a trial-and-error
approach. In that case, give the HMO a try one year, then go back to a more choice-filled
environment if you don't like it.
It's also good to know how your employer pays for insurance. You probably assume the company is just buying insurance plans for everyone. But maybe not. If it's a big company or organization, chances are it self insures. That means the company actually pays your medical bills out of its own pocket and hires an outside firm, often with an insurance company name, to handle the claims paperwork. If your company self insures, then that means the company itself is making many coverage decisions and shouldn't be able to pass off responsibility to the health plan. Bug your human resources department if there's something you don't like about a self-insured plan.
If you are elderly or disabled and get Medicare insurance, you'll find many of the same choices are coming your way in 1999 as Medicare introduces what it calls Medicare+Choice. The new format introduces some alternatives to traditional fee-for-service Medicare and the HMO option that has been available for several years. However, many of these choices, such as a Medicare PPO or medical savings account, won't actually be available for months or years, until the marketplace catches up and begins offering them.
Meanwhile, behind the scenes at the big HMOs, a trend has been developing that might seem way too technical for the average person to care about. But it could be quite important to you if you ever get into a coverage dispute with your health plan. Some HMOs are passing on to doctor groups the financial responsibility for their members. That means that while the doctors follow general guidelines about what the insurance policy covers, they have to make the books balance, and must make a lot of decisions about what medical care gets done and what doesn't. This internal game of hot potato has implications for consumers because whoever takes on the risk doctors, HMOs, has an incentive to save money and withhold care. They might wisely jettison unnecessary tests and procedures, or they might cut a corner that's very important to you.
If you know where the medical buck stops, you'll have a better chance of figuring out who to complain to. Instead of writing that nasty letter to the medical director of the HMO, you'd be writing it to the medical director of the doctor group. Let's hope you'll never have to use this newfound knowledge.