Choosing a HEALTH INSURANCE plan that is best for you and your family is one of the most IMPORTANT decisions you'll ever make.
In the past, if you had a bone or muscle problem you went to the orthopaedic surgeon of your choice who determined the cause. You and your orthopaedic surgeon discussed your treatment options and worked together to achieve a successful outcome. Millions of Americans have overcome bone and muscle problems and enjoy active lives because of this partnership with their orthopaedic surgeons.
Today, we are in an era of managed care. It's a new experience for most people. Managed care companies may decide what doctor you will see and when, and what treatments will be covered. It requires you to make some important decisions because not all managed care plans are the same.
Your orthopaedic surgeon is your advocate. He or she wants you to learn as much as you can about the health plans in your area and about what choices you have before you make a selection. This brochure will explain your choices, including the selection of a point-of-servioce option which allows you to see the doctor of your choice.
The health care environment may be changing, but your orthopaedic surgeon's commitment to your health and well-being remains the same.
How do the plans WORK?
Most Americans have health insurance through their employers, and every year more employers offer insurance coverage by managed care organizations (MCOs). These are mainly health maintenance organizations (HMOs) and preferred provider organizations (PPOs). Employers like the plans because the cost of insurance coverage is less. These plans lower the cost of your care by regulating who you see for health care or what treatments you receive.
A managed care organization may require you to see a primary care physician first, who will determine whether to refer you to an orthopaedic surgeon within their system. In most cases, the managed care organization will not pay for a visit to an orthopaedic surgeon unless you get a referral. If you see an orthopaedic surgeon without a referral, you may have to pay for all or most of the cost of the visit out-of-pocket and find yourself with no insurance for needed tests or procedures. This can be true, even if you have Medicare coverage.
A PPO will allow you to see only the doctors who belong to the PPO network. If your orthopaedic surgeon is not on the list of "approved" providers who are part of the PPO plan, you'll have to pay an extra fee to see him or her.
When offering health insurance plans to their employees, most employers include a point-of-service option among the selections. This costs a small amount, but gives you the ability to see the specialist of your choice.
What about COST?
Don't just select a health insurance plan simply because it is the least expensive. Think about your health insurance as you would other products you buy. You get what you pay for.
People who make hasty decisions and select a health plan only to save money may end up disillusioned. That could have been avoided by spending a little money for the monthly plan that allowed greater access to the care they needed.
Be a wise consumer. Ask these questions:
Can you choose your own DOCTOR?
Many people prefer to be treated by a doctor they know and trust. That's important for the patient who has been seeing the same doctor for years, and for the person who hears good things about the doctor from a relative or close friend. Ask these questions:
Do some plans let you CHOOSE?
There are options in some managed care insurance plans, called "point-of-service," that allow you to choose the orthopaedic surgeon or other specialists you want to see. This option is likely to cost more than the basic plan but gives you a choice. People with a point-of-service option often find that for most routine care they are comfortable with a doctor who is part of the managed care plan. However, they appreciate having the freedom to seek care from the specialist they choose when it is needed.
If you're considering a point-of-service option, ask these questions:
What are other 'ACCESS TO CARE' issues?
Convenience is important. Are the orthopaedic surgeon's office and other services, such as physical therapy, nearby? Do you have to go somewhere else for an X-ray or can it be done in the doctor's office? Does the plan use a hospital nearby? Can you select a hospital for your treatment? Will the plan refer you to a specialist for treatment or just consultation to advise the plan's doctor about a treatment plan?
Keep in mind that as you get older, you may need annual diagnostic tests. You may need to take prescription drugs daily. You may need the medical care of a specialist such as an orthopaedic surgeon.
Orthopaedic surgeons are the medical experts on bones and joints, muscles and ligaments of almost your entire body-from the top of your spine to your hips, knees and toes.
Orthopaedists diagnose and provide nonsurgical and surgical treatments; prescribe medications and braces; apply casts; and supervise physical therapy.
What about care that I may need in the FUTURE?
You may not need the medical care today, but you should know now what you may need to know in the future. Ask these questions:
What else can you DO?
Does the plan have a "report card" and score for quality of care and performance? Ask for a copy. Ask to see the results of patient satisfaction surveys. Ask your friends and coworkers who are in the plan if they are satisfied. If they are not in the plan, why not? Ask your doctor for his or her opinion about the coverage of the plan, particularly if you have special medical needs.
What if you're NOT happy with a plan?
Investigate whether your plan has a timely appeals process. It may be lengthy, but be active on your own behalf. If you are not able to get a quick resolution of your concerns with the plan and the treatment you may or may not be receiving, tell your employer.
Talk to your Human Resources or Health Benefits managers. Your employer wants you to remain a healthy, productive worker. Your employer wants the health care plan to treat you well. It's good business. Training temporary or permanent replacements if you're not in good health is costly for your employer.
Asking questions is the best way to learn about health insurance plans.
Your orthopaedist is a medical doctor with extensive training in the diagnosis and nonsurgical and surgical treatment of the musculoskeletal system, including bones, joints, ligaments, tendons, muscles and nerves.
©1996 American Academy of Orthopaedic Surgeons
This material may not be modified without the express written permission of the American Academy of Orthopaedic Surgeons.