How to Determine What Type of Coverage Is Best For

How to Determine what Type of Coverage is best for?

1. A Young Single Employee:

Young people often do not have established physician relationships, so for you the restricted provider list of a managed care plan may not be a concern. If you're healthy, you may be better off choosing the lowest cost plan available -- as long as you can afford any out-of-pocket costs of that plan. For example, if you chose a lower cost plan that has a high out-of-pocket potential cost (such as a deductible or hospital pre-admission copayment), you must be able to afford that cost.

In comparison, if you are projecting significant medical expenses for the future, the plan with the least amount of out-of-pocket potential may be the best choice -- presuming the provider selection is acceptable.

Note: If you're a woman, you should check to see if your current OB/GYN doctor is a provider on the plan you're considering. Many managed care plans today allow a woman to see her OB/GYN for an annual exam without having to be referred from a Primary Care Physician. Many OB/GYNs do not act as Primary Care Physicians in managed care plans, so it may be necessary to check the specialist section of the provider directory.

2. A Family with Young Children:

For families with young children, the most common expenses are pediatric visits and immunizations. These visits are typically frequent, so it may be more cost effective to choose a managed care program with a low copayment for office visits -- as long as the provider selection is acceptable to you.

3. A Spouse Who has Other Coverage:

An employee who must decide whether to take coverage from his/her employer or from a spouse's employer often bases his/her decision on the types of coverage available and the costs of the alternative plans. For example:

 If one employer offers managed care plans and the other offers a plan that provides more freedom of choice, the individual may prefer one above the other.  If the employee payroll contributions for spousal coverage are high at both employers but contributions for employee-only coverage are relatively low, both the employee and the spouse may want to enroll for employee-only coverage at their respective employers.

Another issue to consider is whether your employer's plan includes a working dependent provision. This provision states that if your spouse is eligible for coverage through his/her employer, your spouse is required to take that employer's coverage or pay a surcharge to be covered under your plan.

4. An Individual with a Dependent Living Away from Home:

Many managed care plans provide only emergency care for a student away from home. Even some plans with providers in the area where the dependent lives will not allow the dependent to access those providers. Since all family members must enroll in the same type of plan, you must weigh the advantages of choosing a more expensive plan, such as a Preferred Provider Organization (PPO). That plan allows freedom of provider choice to your family members. Another option is to check into any separate coverage offered to students through their colleges or universities.