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Opinions of Tuesday, 7 May 2002

Columnist: Assoku, Samuel A.

Health Insurance 101: What you Need

Please allow me to share my thoughts on the health insurance debate, since it has become a hot issue on the political platform. Any consideration of health insurance as an alternative for cash and carry should be guided by some general policies and procedures. It can be argued that this issue has to be seriously addressed in the 2004 elections, if the current political consciousness of Ghanaians is anything to go by.

As an public administrator in payroll and benefit administration for the State of Ohio, I will like to throw some light on the some underlying principles and policies that can guide the general administration of health insurance plans. Attention has been given in this piece, to a variety of health insurance plans that can be available for employees, about the information to be given to employees to make informed decisions, about choices one have to make to fully benefit from the scheme, concerning the mechanics of how the insurance plan works, and the implications for selecting a particular plan.

Among the health care plan options to be made available, some could be organized along the lines of Preferred Provider Organization (PPO), and Health Maintenance Organization (HMO).While the PPOs are an extensive network of carefully selected physicians and hospitals from which an employee does not need to select a particular physician, the HMO provides coverage and care through a specified list of physicians and hospitals. HMOs also require one to select a primary care physician (PCP) to provide and coordinate all care.

Firstly, information from the employer has to be sent directly to employees to help in deciding which option is best for them. Among this information should be a Health Plan Report Card, which is an evaluation of all available plans of the quality of care delivered by each health plan. This will help an employee to determine which plan is best suited for them and/or their family. This report can be gathered by a Committee for Quality Assurance(CQA), an organization that will judge the performance of a health plan against its requirements.

Composite grades can be given for customer satisfaction, preventive care for adults, preventive care for children, comprehensive diabetes care, quality measures for doctors, and heart related care. An example of factors considered for customer satisfaction will include claims processing, courteous and helpful providers, customer services etc. Quality measure that can be given for doctors may include turnover rate for PCP. Every HMO available should be accredited by the CQA based on data collected from previous year performance.

Employees may also be given additional information such as Benefits Comparison Chart and Guide, directly from various health plans. A worksheet that will accompany this information, should allow employees to examine their location, select which plans are available in the region or city where they live or work. It should also allow them to select their benefit information, e.g. emergency room, prescription drugs, therapies etc., that is most important to them and their family. One has to be able to select ones preferred doctor and hospital, provided their preferred selection is part of the health plan's network.

Among the most important factors to be taken into consideration in the selection of a plan is your needs. Factors important to you and your family in choosing a plan calls for seeking answers as to whether there is availability of disease management program or care for a specific chronic disease, coverage for specific prescriptions, and/or coverage when you are outside the health plan's service area for a brief or extended periods of time. Nonetheless, the cost of the choice of plan is equally important.

To determine the cost of the choice of your health plan, it will be significant to understand the terms that will be associated with the coverage. Such terms as Balance Billing, Copayments, Deductible, Formulary, Network, Non-Network, Out-of-Pocket Maximum, Effective Dates, Generic Drug, Medical Necessity, and Medical Emergency, should be defined in detail and copied to the insured , to clear any misunderstanding or doubts. While the employee will pay for a fraction of the premium at the beginning of each month, the employer or the state will subsidize substantial amount of the premium, which will usually be about 95%.

Some plans can cover 100% of cost for any patient care, while others may cover 90%, 80%, or 70%, depending on what plan you select. That means any additional expenses not covered by the plan will have to be borne by the employee or patient. In other words, the insured will benefit from the full coverage only when the deductibles are paid in full. The same will apply to drugs that will be prescribed to the employee or the ensured.

Another health plans that employees should benefit are the dental and vision plans. With this type of insurance, the employer or the state could pay the entire cost for employees and their dependents. An employee will be eligible only after one year of continuous service. The insured may receive treatment from any licensed doctor for their dental or vision needs.

However, if one receive treatment from a Vision Plan (VP) or Dental Plan (DP) member doctor, employee will have to copay, which will be the percentage of charges for which you are responsible when receiving covered services. If you use a non-member doctor, you pay the entire amount and submit the expenses to the VP or DP for reimbursement according to a graduating cost plan after the copayment.

Besides these, there should be other supplemental insurance policies which families could rely on for financial security. An employee may purchase this coverage to supplement their basic life insurance provided by the employer.

As a matter of good governance, there should be an overlooking ministry or organization that will ensure the honoring of obligation by both parties, employers and employees. The absence of such due diligence can lead to insurance fraud and medical malpractice.

In sum, it is arguably important to examine all these factors before administering a healthy health care policy, and for one to decide on the healthcare plan to subscribe. A bad selection will make the 'cash and carry' option the most preferred. There have been instances where patients are made to bare exorbitant cost, due not only to misunderstanding of the deductibles and copayment explanations, but also to the degree of sickness of the patient.

SAMUEL A. ASSOKU
Office of Mgt Employee and Business Services
Ohio Dept. of Job And Family Services

Views expressed by the author do not necessarily reflect those of Ghanaweb.