A Road Map to Choosing an HMO Insurance: Consumers are demanding more information about health plans. Here's a guide to some of the questions you may want to ask.

November 14, 1995|By Patricia Meisol | Patricia Meisol,SUN STAFF

Marvelyn Foster is stretched so thin some months that she orders only half a prescription or goes without her asthma medicine altogether because she doesn't have the cash to pay up front, as her insurer requires.

When she chooses a new health plan this month, a decision thousands of people face at this time of year, she'll look for one that doesn't require her to mail in prescription receipts for reimbursement.

"I don't make that much money," the 44-year-old government clerk explains.

Ms. Foster, the mother of two boys, has figured out that low cost isn't always the best reason to choose a health plan. She is among a growing number of consumers who are studying their options carefully to find a health plan that suits their needs, instead of looking at just the bottom line.

As more and more Marylanders make the jump from traditional insurance to health maintenance organizations and other managed care programs, they and their employers are becoming pickier about what they buy.

Selecting the best coverage starts with knowing how managed care plans work, and then asking the right questions. Your choice may depend on factors ranging from how much a plan pays for preventive care to whether you mind flying to a hospital in Cleveland if you need a liver transplant.

Increasingly, private sector employees are expected to move into managed care, which is less costly than traditional insurance, and both insurers and big companies are working hard to promote this option.

Insurance companies such as Cigna, which once confined their message to the back of Forbes magazine, are spending tens of millions of dollars to lure consumers with ads in newspapers and on radio and TV.

Big companies also are encouraging employees to try managed care by helping them judge the quality of plans available. Blue-chips such as IBM are surveying employees to find the best medical plans and providing financial incentives for switching to them.

American Express has ranked health plans for three years based on its employees' reviews, and saw a huge shift from low-ranked plans into top-ranked ones.

In this area, the biggest user satisfaction survey of health insurance plans is done by the federal government's Office of Personnel Management. Your plan may differ, but this survey will tell you what federal employees think of plans offered by the insurers you are considering. A guide to the federal plans is published by Consumers' Checkbook in Washington and is on newsstands now. The paperback, which is priced at $8.95, also can be ordered by calling (800) 475-7283.

With relatively little information available, cost is still the biggest factor people consider, says Bob Davis, executive director of the Maryland Health Care Coalition Inc. As more people choose managed care, that is expected to change.

"In the last year or two years, there's been an absolute mushrooming of demand for managed care plans to furnish more information," Baltimore Gas and Electric benefits manager Elaine Johnston says. "This has become a big issue among managed care plans. The questions are coming from the purchaser and the consumer. Both are saying, 'Hey, tell us more.' "

The utility hopes to begin surveying employees this year for their opinions on the plans.

This year for the first time, BGE is giving employees a work sheet on how to choose a health maintenance organization. When HMOs were introduced in 1988, BGE simply told employees what they were and left it up to the HMO to market itself, says Ms. Johnston.

Minimum standards

But since 1991, when an "avalanche" of people began moving into managed care, the utility decided it needed to do more. It also tells its 8,000 employees which HMOs meet minimum industry standards, and has told the plans that don't they must obtain the stamp of approval from national accrediting groups by 1997.

At its simplest, managed care means that a health insurance card no longer gives the bearer carte blanche to buy medical care. Instead, patients are directed to a specific set of doctors, hospitals, laboratories, even drug stores that give the best deal to the insurer -- in terms of cost, quality service or both.

None of this much matters if you are healthy. How a plan works when you are sick is what consumers need to know. To start, it helps to know the basic forms of managed care:

* The HMO: The most restrictive type of coverage. Subscribers choose a primary care doctor in the group, who acts as a gatekeeper and controls what services a patient may obtain. The consumer is limited to the doctors, hospitals or other services associated with the HMO. Some HMOs such as the Columbia Medical Plan or Kaiser Permanente have their own staffs and offices, but others rely on doctors in private practice and contract separately with hospitals or other health care providers for items ranging from heart surgery to colonoscopies.

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