Questions to Ask When Shopping for a Health Insurance Plan

Is the health insurance plan registered with the American Association of Health Plans (www.aahp.org) or the National Committee for Quality Assurance (www.ncqa.org; 202-9553500)? (Note: The National Committee for Quality Assurance Web site allows you to create online report cards for any health plan or plans you’re considering. This Web site is definitely worth checking out.)
Is the plan you’re considering suited to the needs of young families?
How long do you have to add your newborn to the plan? (Most health insurance companies only give you 30 days to add your baby to your plan. If you miss this window of opportunity, you have to wait until the next open enrollment period - something that likely means your baby will go uninsured until then.)
Are all of the hospitals covered by the plan accredited by the Joint Commission on Accreditation of Healthcare Organizations (www.jcaho.org/; 630-792-5000)?
Does at least one of the hospitals covered by the plan have an extensive department in any specialty you or your baby might require (for example, a neonatal intensive care unit)?
How many of the physicians within the plan are board certified?
Are the physicians or midwives who are covered by the health insurance plan experienced and highly respected professionals? Do they have specialized training in such areas as infertility and high-risk pregnancy?
Are there enough physicians or midwives for you to choose from? (You should think twice before joining a plan that has fewer than 3 specialists in any specialty or fewer than 10 primary care physicians.)
What is the rate of turnover among physicians or midwives?
Do the physicians or midwives covered by the plan have offices that are conveniently located?
If you decide to use the services of a physician or midwife outside the plan, what percentage of the cost of their services, if any, will be covered by the health insurance plan?
How are treatment decisions made?
Which drugs and treatments are and are not covered by the plan?
If experimental treatments are not covered, how does the health insurance plan go about defining what’s experimental and what’s not?
Are there any restrictions on medical coverage? For example, does your primary-care doctor or the health insurance plan administrator have to give the go-ahead before you show up at an emergency room?
What type of nonemergency care, if any, is available to you when you travel?
Are the doctors within the plan required to sign a “gag clause” that prohibits them from telling patients about expensive or experimental treatments that aren’t covered by the plan?
Does the health insurance plan dictate standardized procedures for certain diseases or medical conditions (for example, what is its policy regarding vaginal births after cesareans)?
Is there a cap on the number of referrals to specialists or for expensive tests that a physician can order in a year (or other financial disincentives to utilize services)?
Does the plan cover the cost of obtaining a second opinion?
What types of infertility-related services are covered by the plan? How many sessions or treatments are covered?
Are alternative therapies, such as the services of chiropractors and acupuncturists, covered by the plan?
Are prenatal visits, well-baby care, and immunizations covered by the plan?
What is the co-pay (that is, the amount of money you’re required to pay out of your own pocket) for prenatal visits, a vaginal or cesarean birth, ultrasounds, prenatal testing, and other types of services?
What is the deductible you are required to pay for a particular time period (usually per person/per year)?