When you pay a premium to an insurance company, the company promises to pay for your care. In order to have enough money to pay for your care, an insurance company must save enough from the premiums it collects now so that it can pay bills later. Money that an insurance company saves to pay future claims is called "Reserves." State insurance commissions monitor insurance company reserves. A company with reserves that are too low may not be able to pay future claims. A company with reserves that are too high may be skimping on paying claims. A.M. Best, Moody's Investor Service, Duff & Phelps, and Standard & Poor's rate the financial health of insurance companies, including reserves. To get information on how a plan was rated, you can ask an insurance agent, call your state insurance commission, ask the company directly, or call the reference department of your library.
Not only must a health plan have enough money to pay claims, it must also pay claims efficiently. How long does the plan take to pay claims submitted by individuals or providers? Is the claims review process reasonable or is it full of roadblocks? What process does the plan have to respond to complaints? Has the state insurance commission received complaints about the plan from members or providers?
The term "Health Plan" is often used when the same organization that provides insurance also provides your health care. "Providers" include physicians, nurses, other health professionals, hospitals and clinics, and other health care organizations. When an insurance company pays for care only from certain providers or pays a greater percentage for those providers, then these providers are called a "Provider Network" or "Preferred Providers."
When you consider joining a health plan with a provider network, you should evaluate the quality of the plan's medical services. How many providers of what specialty are in their network? How are providers selected? How many are board certified? Are their providers located near you and are they accepting new patients? How long is the wait for appointments? Does the plan allow a get-acquainted visit with a provider before making a decision to join the plan? What happens if you need services by providers outside the network? Does the plan provide urgent care after hours? Does the plan have a phone line for health advice? How does the plan provide for emergency care and care for members traveling in other states or countries?
What information does the health plan collect and report concerning quality of care? Does it have a "quality report card"? Does it track, for example, immunization rates for children and cancer screening rates for adults? Does the plan have "Centers of Excellence" that specialize in treating particular conditions? Has the plan or its providers been rated by local magazines or employer group coalitions? Are any of the plan's hospitals or physicians on a list of top providers, such as the HCIA list of the top 100 U.S. hospitals? What percentage of people leave the plan each year and why? What plans or providers do other doctors, nurses, your friends, your family, and your co-workers recommend?
