Seek out comprehensive coverage. A good plan will cover your legitimate health care without burdening you with oversized debt.
"The idea of ‘Cadillac’ coverage vs. basic coverage isn’t an appropriate way to think about health insurance," said Mila Kofman, Maine’s superintendent of insurance. "It has to give you the care you need, when you need it, and some financial security so you don’t end up out on the street."
What you want is a plan that has no caps on specific coverages. But if you have to choose, pick a plan offering unlimited coverage for hospital and outpatient treatment, doctor visits, drugs, and diagnostic and imaging tests. When it comes to lifetime coverage maximums, unlimited is best and $2 million should be the minimum. Ideally, there should be a single deductible for everything or, at most, one deductible for drugs and one for everything else. And the policy should pay for 100 percent of all expenses once your out-of-pocket payments hit a certain amount, such as $5,000 or $10,000.
If you are healthy now, do not buy a plan based on the assumption that you will stay that way. Don’t think you can safely go without drug coverage, for example, because you don’t take any prescriptions regularly today. "You can’t know in advance if you’re going to be among the .01 percent of people who needs the $20,000-a-month biologic drug," said Gary Claxton, a vice president of the nonprofit Kaiser Family Foundation, a health-policy research organization. "What’s important is if you get really sick, are you going to lose everything?"
Consider trade-offs carefully. If you have to make a trade-off to lower your premium, Claxton and Pollitz suggest opting for a higher deductible and a higher out-of-pocket limit rather than fixed dollar limits on services. Better to use up part of your retirement savings paying $10,000 up front than to lose your whole nest egg paying a $90,000 medical bill after your policy’s limits are exhausted.
With such a high deductible, in years when you are relatively healthy you might never collect anything from your health insurance. To economize on routine care, take advantage of free community health screenings, low-cost or free community health clinics, immediate-care clinics offered in some drugstores, and low-priced generic prescriptions sold at Target, Walmart, and elsewhere.
If your financial situation is such that you can afford neither the higher premiums of a more comprehensive policy nor high deductibles, you really have no good choices, Pollitz said, adding, "It’s why we need to fix our health-care system."
Check out the policy and company. You can, at least, take some steps to choose the best plan you can afford. First, see 7 Signs a Health Plan Might Be Junk, to learn to spot the most dangerous pitfalls and the preferred alternatives.
Use the Web to research insurers you’re considering. The National Association of Insurance Commissioners posts complaint information online at www.naic.org.
Entering the name of the company and policy in a search engine can’t hurt either. Consumers who did that recently would have discovered that Mid-West National was a subsidiary of HealthMarkets, whose disclosure and claims handling drew many customers’ ire. Last year, HealthMarkets was fined $20 million after a multi-state investigation of its sales practices and claims handling.
Don’t rely on the salesperson’s word. Jeffrey E. Miller, the Florida man whose policy failed to cover much of his cancer treatment, recalls being bombarded with e-mail and calls when he began shopping for insurance. "The salesman for the policy I bought told me it was great, and I was going to be covered, and it paid up to $100,000 for a hospital stay," he said. "But the insurance has turned out to pay very little."
Pollitz advises anyone with questions about their policy to ask the agent and get answers in writing. "Then if it turns out not to be true," she said, "you can complain."