Insurance Law FAQs

Employee Welfare Plans: Considerations when you're shopping for a health-care plan

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Employee Welfare Plans: Considerations when you're shopping for a health-care plan

  • Where are the providers located? Are they convenient to your employees?

  • To what extent and at what cost will the plan extend to family members of employee?

  • What kinds of doctors are providers? Are there family practitioners? Pediatricians? Internists? Other Specialists?

  • Is it worthwhile to offer cash bonuses to employees who choose to a spouse or other family member's plan rather than yours?

  • Are the doctors accepting new patients?

  • Are there specialists? Are specialists available only by referral, or may your employees see a specialist on their own?

  • What hospital is designated for your plan? Is it convenient to your employees?

  • Does the plan offer urgent care centers or after-hours care? Is it convenient?

  • How long does a person have to wait for an appointment for routine check-ups?

  • Does the plan use a "gatekeeper?" A gatekeeper decides whether certain procedures will be covered. A gatekeeper may determine whether a person may be referred for mental-health care.

  • How does the plan rate? Providers and hospitals are audited, accredited, and rated by independent inspectors. The ratings allow you to compare the providers in your area on a defined set of criteria. You can ask the health plans you are considering about their most recent "HEDIS" report. ("HEDIS" refers to the full name of the report: "Health Plan Employer Data and Information Set.")

  • Does the medical plan link reimbursement to its physicians based on the quality of care they provide?

  • How does the plan cover people with chronic disease, such as diabetes?

  • Under what conditions will the plan cover emergency room visits? Does reimbursement depend on the patient's reasonable judgment of whether a medical emergency exists?

  • Are the health plan's finances stable?

  • How quickly does the health plan process claims?

  • How does the plan handle complaints and requests for review? Is an outside panel used? Is there an arbitration or mediation provision? How long does a grievance or appeal take?

  • How many members have left the plan in the last year or so? A turnover rate exceeding 10 percent may be a source of concern about the network of physicians, the services, or something else.

  • Ask for references of other employers in the area whose business is about the size of your business and call them. Ask for names of a few employers of your size who have left the plan recently to find out about possible problems with the plan.

  • Call the Better Business Bureau to see if anybody has lodged a complaint.

  • How do you feel about the people with whom you have had contact? Do you like them? Are they responsive? Do they return telephone calls?

  • There may be a group of businesses in your area that pooled together to purchase health coverage. Call your local Chamber of Commerce, or contact the National Business Coalition on Health, 202-775-9300.

  • You also can use a broker or consultant to help you decide what sort of coverage would be best for your company and help you obtain it.

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