Plan Value: Balancing Benefits and Costs
Choice of Providers
Reputation and Quality of Insurer
Make Decisions

Once your broker or you have contacted various insurers and gotten quotes on a range of products, it's time to look over what you have found. Below we explain how to evaluate the results of your search (be sure to consider at least two or three plans).

In general, think about:

• The overall value of each plan. Does it provide ample coverage at a reasonable cost?
• Choice of providers. Will your employees be able to visit doctors and other providers they want?
• The insurer or health plan itself. Is it a stable company with quality customer services?

Plan Value: Balancing Benefits and Costs

Health insurance products are complicated, and getting more so. When shopping for plans, you'll want to look carefully at coverage for the services your employees will use most, such as office visits and prescription drugs. Even though it's used less frequently, coverage for hospitalization is also critical.

In addition to these basics, below we list some specific benefit categories that may be worth a careful review. Depending on your employees' circumstances, some or all of these may make a big difference for your business.

• The specific structure of the pharmacy benefit. Coverage may involve different levels of payment depending on whether drugs are generic or brand name, and whether they are included in the health plan's formulary.
• Behavioral health coverage. California's mental health parity law (AB88) requires that care for certain severe mental health diagnoses and childhood emotional disturbances be provided at the same member cost as medical care. As a result, information about behavioral health coverage can be confusing, because coverage differs depending on whether or not the diagnosis is included in the AB88 list.
• Annual out-of-pocket maximum. If the consumer reaches the out-of-pocket maximum, then the health plan waives out-of-pocket charges for the remainder of the year. Lately these maximums have been rising. Though it's unlikely that any of your employees will reach this level, if you choose a plan with lots of cost-sharing features it can bring peace of mind to know that no matter what unforeseen needs emerge, there is a limit to how much a particular individual or family will have to pay.

In the tool box, use the "Plan Type/Price Range Generator" to see the types of plans you can offer and their associated costs.

Choice of Providers
As we mentioned earlier, choice of providers may be an important issue to you and your employees. Make sure you understand which providers, hospitals, and medical groups can be used by plan participants. If you or your employees aren't comfortable with the choices offered, you may well want to consider a different plan.

Reputation and Quality of Insurer

A plan may look good, but if the insurer turns out to be hard to deal with—or if it goes bankrupt, for that matter—you'll likely wish you had picked a different plan. Do a little research to make sure that your potential insurer:

• Is financially stable.
• Gets high marks in quality from an unbiased source.
• Makes customer service a priority.

Financial Stability
You can find out if your insurer is financially stable by researching its financial rating. A number of companies provide this service, usually for free, though some companies may offer more information at a price.

In the tool box, see "Evaluating Insurers and Health Plans" for more information.

Quality of Health Care
The quality of health care varies widely. In addition to doctors, hospitals, and medical groups, insurers play an important role in seeing that you receive high-quality health services. Be sure to look into the insurer's reputation and ratings for the quality of care provided under their plan.

In the tool box, see "Evaluating Health Coverage" for information on comparing health plans and products, and how to factor quality considerations in your health care decisions.

Customer Service
Look for an insurer who makes it easy for you to pay the bill and get help when you need it. Your broker can advise you on which insurers provide great service, and which give employers health care headaches.

The best insurers also make it easy for employees to:

• Find provider information. Most insurers have printed provider directories that customer service representatives can mail to participants upon request. Some also offer provider directories online.
• Resolve claims quickly and efficiently. There's nothing more annoying for employees and employers alike than dealing with an insurer who incorrectly processes claims, or processes them so long after a service that it makes it difficult to fix errors.
• Reach someone who can help them resolve a problem. Look for insurer customer service representatives who can handle both claims and member service requests, such as ordering a member ID card or changing primary care physicians.

Make Decisions

If you've found a plan that suits your needs, it's time to move to the next step, which involves signing a contract and implementing the plan. You can skip the rest of this section and move to Step 6: Close the Deal.

If, on the other hand, after evaluating several plans you decide that none of the options looks affordable, you'll need to put some thought into what to do next. If you're way off your target budget, it may not be the right time to purchase group coverage (especially considering that the costs will likely increase each year). If you're in the ballpark, however, there may be ways to shave the costs down.

If it really looks like you won't be able to afford group coverage, you should consider some alternatives.

In the tool box, see "Cost-Saving Strategies" and "Alternatives to Offering Group Coverage."