ROANOKE TIMES
Copyright (c) 1996, Roanoke Times
DATE: Sunday, October 27, 1996 TAG: 9610250032
SECTION: BUSINESS PAGE: 1 EDITION: METRO
COLUMN: health care
SOURCE: SANDRA BROWN KELLY
Large envelopes containing instructions about next year's "benefits enrollment" have arrived on employees' desks at my office.
We have two weeks to make up our minds about the type of health care plan we want from among three versions offered.
This is the time of year when workers in many companies start speculating about whether they can count on staying well and take the cheapest, lowest-coverage plan, or if they're "so old" they'd better "get it all."
For some of us, the choices aren't very complicated, but selecting the right one still requires thought, and the time seemed right to consult an expert, someone like Rebecca Pollard.
Since 1990, Pollard has been a partner with Carter Garrett Jr. in Corporate Concepts Inc., a Roanoke Valley employee-benefits consulting firm. But she took her first insurance job 25 years ago.
Pollard started with General Electric Co. in Louisville, Ky. Later, she worked for GE in Salem and then with State Farm Insurance. Next, she managed the Associates in Psychiatry practice, where she helped patients who came in with insurance cards but often didn't know what benefits those cards represented. Later, as a marketing service representative for Trigon Blue Cross Blue Shield, she helped companies help their employees understand benefits.
Her firm, which grew from two people in 1990 to 10 now, wears two hats. Its staff can serve as consultants reviewing a company's health-insurance contracts and helping negotiate renewals or serve as brokers and find health insurance for a company.
All of that means she has been on both the corporate and the customer side of health care insurance. With that as background, here are Pollard's suggestions for reviewing health-insurance plans:
* Look at what the insurance contract excludes as well as what's covered. Some things that might be excluded are transplants, coverage for treatment of TMJ (temporomandibular joint syndrome in which the jawbone doesn't function properly), durable medical equipment such as shoe lifts and birth control pills.
* Look for the dollar limitations in a contract. If you or a family member needs a special service over a long period, such as physical or speech therapy, determine if the limit will allow it. For a diabetic person, a policy with a durable medical device limit of $2,000 might not fully pay for an insulin pump, Pollard said.
* When considering an indemnity plan, a plan that allows you complete freedom to seek care from any doctor or facility, check the amount of deductible required and the out-of-pocket limit, which is the point where you stop paying and the policy pays 100 percent. The out-of-pocket limit is more important than the deductible.
* If you're selecting a managed-care plan, such as an HMO (Health Maintenance Organization) or PPO (Preferred Provider Organization), be aware of the penalties for going outside the designated networks of doctors and hospitals.
* Also when considering a managed-care plan, ask to see the insurance company's list of Centers of Excellence. These will be the places you would be directed for treatment that is not provided at your local hospital or where the company believes the treatment can be gotten more efficiently. Look at the list to see if it has a broad representation of specialties.
* In selecting any policy, ask how emergencies that happen while you're traveling are handled, including travel outside the country.
* Ask the insurance agent or insurance company what percentile the company is in for reimbursement of claims. A company in the 70th percentile denies more claims than a company in the 90th percentile. The lower the number, the more likely a patient will be billed for the "remainder" of a charge.
In addition to the above, here are some questions small-business owners should ask when looking at insurance plans:
* Will the plan cover all pre-existing conditions for employees?
* If the business owner switches plans while another plan is in effect, will employees get credit for deductible amounts already paid?
* How long are rates guaranteed? Most rates are guaranteed for a year, but the fine print might warn that after that the rates will be reviewed every six months and subject to increase.
* What percentage of employee participation does the company need to have the group covered?
* What's excluded from coverage? What would be the additional cost for that coverage?
And don't be surprised if your insurance company's representatives can't answer some of the questions. They can find out the information, however, and should if they want your business.
Sandra Brown Kelly covers health and medicine. You can reach her at 1-800-346-1234, x393, or 981-3393 or at biznews@roanoke.infi.net
LENGTH: Medium: 89 linesby CNB