How to Determine the Quality of a Health Plan

To determine the quality of a health plan, you will need to carefully read the plan's coverage book, and then look to independent sources that have reviewed the plan. Many consumer and business groups now issue "report cards" that survey plan members for satisfaction and include information on quality of service.

Difficulty: Moderate

Instructions

Things You'll Need:

• Coverage booklet

1. Consult with coworkers, employers and others who are covered by the plan in question or have information regarding the plan.

2. Have prospective health plans send you a copy of their new member guide or coverage book. Look at their "best practices," which will tell you how they cover certain medical conditions.

3. See if the plan reviews the qualifications of doctors before they are hired. Also check with the plan to see if they review the quality of care given by their hospitals.

4. Find out how the plans resolve member complaints. And also find out how many members have left the plan each year.

5. Ask the health plan or your state insurance department how many complaints were filed against the plan in the previous year and how many were upheld. Your state's Department of Health can also give you information on the health plan.

6. Contact agencies that review health plans for quality of care, such as the National Committee for Quality Assurance (NCQA), to see what kind of accreditation (seal of approval rating) the plan has received.

7. Check with state consumer and business groups for additional information on programs such as "report cards" that report on quality of service by a plan's members.

Tips & Warnings

• Also check with The American Accreditation Healthcare Commission/URAC and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) for more information about quality reviews of health plans.
• Contact the Health Insurance Organization of America for a directory of state insurance departments.
• Under a new law called the Health Insurance Portability and Accountability Act, health plans are now required to immediately cover pre-existing conditions if you have been insured for the previous 12 months. Before the law, health plans had a waiting period before they would cover a pre-existing condition.

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