3 Steps to Choosing a Health Insurance Plan - Merit

All health plans have trade-offs. You must decide what is most important to you based on your own personal needs.  This information is provided as a tool to help you make an informed decision.

STEP ONE: Estimate what your out-of-pocket medical expenses for the following year could be for each plan you are considering.

To make your estimate as accurate as possible, consider the lifestyle and family status and financial status factors listed below.  It may be wise to do both an estimate based on an average of your past medical care, and an estimate with a higher usage of medical care.  This will give you a range of what your expenses could be.  This estimate (less premium costs) will also be useful in determining if a health care flexible spending account is appropriate for you, and if so, what your annual contribution should be.

Lifestyle and Family Status Factors to Consider When Estimating Future Medical Expenses

Are you or a family member planning to have a baby? Premiums may change when you switch from Single to Family coverage.  You will also want to pay close attention to hospitalization coverage and costs, well-child coverage, and office visit costs.

Do you (or a family member) travel often? Non-emergency out-of-area medical care requires prior approval with the managed care plan, Blue Access.

Will you have a family member who needs coverage in another geographic area (e.g., a child attending college)? When you are temporarily out of the area, some plans cover only life threatening emergencies. Under Blue Access, if you will be traveling long-term or have dependents or a family member out of the area for an extended time, you should review the Guest Membership component of the policies.

Financial Factors to Consider When Estimating Future Medical Expenses

  • What is the monthly premium?
  • What is the deductible? Where does it apply?
  • How much is the co-payment for an office visit?
  • What is the co-insurance percentage for services?
  • How much is the out-of-pocket maximum? 
  • What is the structure of the prescription coverage plan?
  • Will you have to pay more than your co-payment/co-insurance amount for medical services; will you be responsible for charges over what your plan considers “usual customary and reasonable” charges? Program 3 Plus and Iowa Select will cover charges from any provider up to what Wellmark BC/BS considers “usual customary and reasonable”.  Participating providers who have contracts with Blue Cross and Blue Shield, including Alliance Select preferred providers and all managed care providers have agreed to accept plan payment levels; you will not owe beyond your co-pay/coinsurance and deductible (if applicable).

What are the financial details pertaining to coverage that may be important to you?  Things you may want to consider are:

Office visits
Emergency room care
Hospital room and board
Preventive services
Treatment of chronic conditions
Inpatient hospital services
Consultations with specialists
Prescription drugs and contraceptives
Hearing exam
X-ray and laboratory services
Physical therapy
Routine physicals
Immunizations
Allergy treatments
Skilled nursing facility care
Hospice care
Well-child care
Routine eye exam
Maternity services (including prenatal care and delivery)
Home health care (e.g., the services of a licensed private duty nurse)
Rental or purchase of medical equipment (e.g., crutches or a wheelchair)
Rehabilitation services including speech, respiratory and occupational therapy
Chiropractic care – Program III Plus and Iowa Select plans cover chiropractic as any other physician.  Managed care plans sometimes require prior approval and may have a limited number of providers.

STEP TWO: Consider the provider access issues below, and keep in mind the Lifestyle and Family Status Factors. 

Do you have to use certain physicians or hospitals?  If so, given the plan’s participating providers,  who (or where) would you choose for:

  • A primary care provider?
  • Specialists?
  • A hospital?

Blue Access  is a  managed care plans which requires the use of specified providers. Program 3 Plus and Iowa Select plans cover any provider, but BC/BS providers can lower out-of-pocket expenses.  Preferred providers with Alliance Select result in additional savings.

Are the treatment locations convenient?

STEP THREE: Weigh your estimates of the possible out-of-pocket costs for the plans you are considering against the provider access issues.  Make your decisions based on the factors which are the most important to you.