How to choose

If you are one of the 65 percent of U.S. workers who has a choice of plans, you may start your selection by weighing the basic differences between HMOs and PPOs. (See Which plan for you?) Typically, the 25 percent of consumers currently enrolled in HMOs pay lower premiums and have fewer out-of-pocket expenses, but cope with a somewhat more restrictive option that dictates the network of providers they can use. About 55 percent of all covered workers are in PPOs.

Consider your health. For survey respondents who were ill, there was very little difference in overall satisfaction scores between HMOs and PPOs. Readers with any of eight chronic ailments--allergies, arthritis, depression or anxiety, diabetes, a heart condition, high blood pressure, high cholesterol, or prostate problems--registered almost the same level of satisfaction with treatment whether they were in an HMO or a PPO. When the condition was back pain, however, PPO members were more satisfied with their treatment.

Look at our Ratings. Some of the plans listed may be available from your employer. Our reader score is based on overall satisfaction with the health plan. We also measured six factors that over the years we have found to be most important in determining patients? overall satisfaction: access to doctors and medical care; choice of doctors; quality of customer support; frequency of billing problems; care doctors provide, and satisfaction with primary-care doctors.

Search out the news. Business news about providers you are considering can be telling. For example, Health Net, a plan that ranked 36 out of 43 PPOs two years ago, fell to the bottom this year. The company says profits increased much less than expected in the first quarter of 2005, partly because of a $67 million pretax charge. All but $1 million of the charge will be used to settle a class-action lawsuit first filed by doctors in 1999. The suit charged Health Net and others with systematically rejecting payments based solely on price without properly reviewing bills. Health Net representatives say the company settled the case to maintain good relations with doctors.

More questions to ask:

Are your current doctors plan providers? Ask to see the plan?s list of physicians to make sure. Call new doctors you want to use to verify that they are still providers for that plan and are willing to take on new patients.

Does the plan pay for alternative-medicine treatments? Most PPOs and HMOs cover chiropractic visits, but only about half cover acupuncture.

If the plans you are offered are not in our Ratings of HMOs and PPOs, you may be able to find information about them on the NCQA Web site at www.healthchoices.org. The group, which is partly funded by the health-care industry, provides report cards on 216 HMOs, but only 20 PPOs. The NCQA reviews appeals and health-plan denial records, interviews staff, and conducts audits of consumer surveys. It rates plans on, among other things access to doctors, chronic-care treatment, the number of qualified providers, and customer service. The NCQA?s data collection, however, requires the cooperation of the health plans themselves, and they are free to withdraw from the program if they choose.

You can also call your state department of insurance to see whether it has received complaints about the plan. For contact information, go to www.naic.org/state_contacts/sid_websites.htm. Once you have signed up, don?t hesitate to report problems to your employer. Sometimes a call from the folks who are paying most of the freight can solve the problem.