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From New York, USA:

My son and daughter have Type 1 diabetes; they are 11 and 9 years old. My husband has Open Enrollment to choose a health insurance plan for next year. I need some help in getting the best health care for my children. We have offered to us an HMO, a POS, and a PPO. How do we choose a plan?


There are many different plans under each company. What I suggest to patients, is to get a list of the common procedure codes your present doctor charges and find out how much each insurance plan reimburses for each code. Common codes include 99212, 99213, 99214, 99215 for office visits of different levels, 81000 for urinalysis and 96425 for venipuncture. (There are other codes that your doctor may use including codes for hospitalization.)

I would make sure you can pick your own doctor even if he or she is out of the plan. Find out how much the "deductible" is for each plan if you go to a doctor who is out of the plan and find out how much the plan allows for visits after you meet the deductible.

If possible pick a plan that allows you to use laboratories, hospitals, and x-ray facilities that your own physician chooses.

In New York State, there is a law (the Spano law) that all insurance companies must reimburse for diabetes supplies. I have heard, however, that some insurance companies are insisting that you use one or two specific brands of meters or syringes. Try to make sure that the plan you choose does not restrict you on the brand of products you choose.

Make sure you do not choose a plan that penalizes your primary care doctor financially if you go out of plan even if the plan officially allows you to use a non-participating doctor. (You will have to ask the plan this directly as some plans have this policy, but forbid the participating doctors to discuss this with their patients.)

Get all information in writing from the insurance plan before you make your final decision! Do not rely on information given over the phone!

Although it is nice to choose a plan that your present doctor participates in, doctors are joining and leaving plans very often these days, so I would be more concerned that the plan you choose has good provision for physicians who are not participants.


[Editor's comment: Anytime you look at the options, look for a "PPO" (Preferred Provider Organization): if there's one or more, start with them. PPO's offer you the option of seeing any doc anytime, without needing to get a referral from a "gatekeeper" primary care doctor, who might not agree with your assessment of the need for a specialist. PPO's will usually cost more, however.

If there are no PPO's on the list, look for an HMO with a POS (Point of Service) option. These plans are also called EPO's, and a few other similar nonsensical terms: they are hybrids, where you can choose to use the gatekeeper concept, or use your own judgement about when to see specialists (if you see a specialist without getting the "gatekeeper's" approval, you'll have a bigger copayment to make).

If you must choose an HMO, find one that allows you to switch primary doctors on the spur of the moment, so if you get one that's a bummer, you aren't stuck with him or her. WWQ]

Original posting 31 Oct 97


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