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Make a plan

The best plan is one that affordably covers all your medical needs - and links you with a conveniently located medical group.

How much medical care do you need?

Step One is simple: assess your medical needs. Think back over the last 12 months - how many times did you see the doctor? Were most of your visits with your Primary Care Physician or did you see specialists? Don't forget Urgent Care and Emergency Room visits. If your health plan covers your spouse or children, tally their medical visits, too.

Using this list as a guide, think ahead to what you might need during the next year. Be sure to include annual preventive care services, such as a physical, gynecological exam and mammogram. If you are expecting a baby or planning a pregnancy, factor in prenatal care visits and a hospital delivery. Some health plans cover genetic counseling and infertility services. If you anticipate the need, write it down.

If you have young children, be sure to include well-baby and well-child check-ups, immunizations and school physicals, along with periodic office visits for illness or injuries.

Once you've compiled this master list of medical needs, you can begin to objectively evaluate each health plan.

Focus on benefit differences

Step two is to compare benefits. At first glance, every health plan may seem about the same. It's true that all the plans you're choosing from offer good medical coverage from a panel of local physicians and hospitals. In terms of covered benefits, you'll find the biggest differences in the following areas:

  • Chiropractic care and complementary medicine: Are chiropractic services covered, and to what extent? Is acupuncture covered?
  • Mental health coverage: What coverage is offered for individual or family counseling services? How big is the panel of providers and what type of referral is needed?
  • Vision care: Does the plan cover annual eye exams and eyeglasses or contact lenses?
  • Fertility services: Are these covered? Where are the services provided?

In addition, check on your prescription costs and drug coverage - how much will each prescription cost you? Also, how responsive is your health plan to its members? If you want wellness classes to help you manage stress, does the plan cover member education classes?
Take, for example, Western Health Advantage. They offer many benefits including:

  • Full benefit coverage for all your needs
  • Conveniently located doctor panel
  • Copay cost per office visit
  • Copay cost for emergency care
  • Copay cost for prescriptions
  • Freedom to choose own doctor
  • Freedom to see specialists in many medical groups
  • Customer service accessibility
  • Health education provided
  • Choice of hospitals

Compare these features and benefits to your own health plan or HMO and this will help you gage benefit differences.

Estimate your costs

Your final step should be determining a plan's affordability. Here's where your master list of medical needs really comes in handy. Begin by noting your monthly paycheck deduction for each of the plans in which you are interested. Then add in your cost for each anticipated medical service. With managed care plans, your cost is a fixed amount called "copayment." Copayments for routine office visits are low; copayments for after-hours urgent care and emergency medical care are much higher.

If you prefer a health plan that allows you to see physicians outside the designated networks (non-network provider), estimating costs is trickier. Under this system, every time you see a non-network provider, you must pay a percentage of the cost of that medical service. If you want the security of knowing exactly how much a trip to the doctor will cost, choose a plan with a fixed copayment.