Main content

    What Health Plan Questions Should I Ask?

    Making Sense of Health Plans

    Health plans come in all shapes and sizes, and making sense of your options can be overwhelming. Many employers offer health insurance coverage, and some offer more than one plan. If your employer doesn’t provide health insurance, there are health plans that offer insurance to individuals.

    Choosing the right doctor for you

    The first step in choosing the right health plan is choosing a doctor. If you have a doctor you like, find out the plans in which he/she participates. You should also consider your special medical needs. If you regularly see a particular cardiologist, allergist or any other specialist, you probably want a plan that lets you continue doing so.

    Back to top

    Think about hospitals/health facilities

    Next, think of the hospitals and health facilities you utilize or may need to utilize. Are the available facilities located close to your home, or would a brief hospitalization require you to load family members in the car for a long road trip? Is it important to you to have diagnostic services such as lab, X-ray, CT, MRI and mammography available close to home? What if you need more specialized care, such as cardiac surgery or cancer services? Would the plan allow you access to the best hospital for that care? Find out which hospitals are affiliated with which plans.

    Back to top

    Think about "networks"

    A complicating factor in all of this is “networks.” The health plan that you choose may allow you to access care through more than one network. A network is a business arrangement between insurance companies, physicians, hospitals, and other health providers, which limits an HMO patient (you) to certain choices. For example, in Los Banos, most physicians are part of two different networks, but only patients enrolled in the Sutter Gould Medical Foundation network are able to access Memorial Hospital Los Banos, Memorial Medical Center in Modesto, and other Northern California centers of excellence within the extensive Sutter Health system.

    If your current health plan (or network) doesn’t allow you to choose a local doctor or hospital, it may be time to choose a new health plan or a new network.

    Back to top

    What about cost?

    Cost is certainly an important consideration in choosing a health plan, but the least expensive plan is not always the best buy. You probably wouldn’t buy the cheapest car that you could find, because other factors, such as safety, reliability, gas mileage, and such, are important to you. The same is true of health plans. You must balance the cost of the plan with those other factors that are important to you and your family.

    While some plans may offer lower monthly premiums, there may be higher deductibles or charges for office visits and out of network care. You may not be able to see the doctor you want, and you may have to use out-of-area specialists and hospitals. Before you make your decision based on cost alone, be sure to look at the out-of-pocket costs (deductibles, co-payments) as well as your ability to choose local providers. It may cost you a little more to be able to choose the doctors and hospitals you want, but for about the same amount per month as dinner and a movie, you and your family could have greater flexibility in obtaining health care services.