Choosing the Best Health Insurance for You.

If you work for a small employer or have an individual policy (a policy that you have purchased directly from the insurance company), your choices may be limited. Large employers may give you more options since they often have several plans to choose from. When deciding which plan to enroll in, carefully assess both the needs of the employee and the rest of the family. The following are some things to consider.

What You Can Afford. Often, your financial situation will make the decision for you. HMOs are significantly cheaper, and limit your out-of-pocket costs. However, if you want more autonomy in making your healthcare decisions, PPOs are a better bet.

How affordable is the cost of the health care?

· How much will it cost me on a monthly basis?
Are there deductibles I must pay before the insurance begins to help cover my costs?
After I have met the deductible, what part of my costs are paid by the plan?
If I use doctors outside a plan's network, how much more will I pay to get care?

Choosing Your Doctor. Also, the relationship you have with your family doctor may be a factor in your decision. If you like your doctor and he or she is not a member of the HMO network, you will probably want to choose a PPO so that you can continue seeing him or her. However, if you do not have a single source of care, or are looking to change doctors, either option would work for you.

HMO or PPO? Would an HMO or a PPO better suit your needs? If you are looking at an HMO, are all your medical providers (doctors, specialists, therapists, durable medical suppliers, pharmacies, etc.) on the plan? This is also a consideration for a PPO since a PPO plan covers less for out-of-network providers. The types of services covered and the amount of coverage usually differ between HMOs and PPOs, too.

Whatever you decide, it will be better than having no insurance at all. Some people are perfectly happy with their HMOs, while others curse them bitterly.

Some rave about their PPO plan, while others complain about the higher costs involved. Consider your options carefully and choose what makes the most sense for you and your family.

Case Management Services. Many insurance companies offer case management services for people who have frequent emergencies or hospital admissions, or when a person is first diagnosed with a disability or severe medical condition. The role of the case manager, who is employed by the insurance company, is to coordinate the care for the insured person by considering the person's individual needs, the terms of the policy, and the cost and applicability of recommended services and treatments.

Policy Limits and Exclusions. Carefully check the policy's limits and exclusions, such as: What are the deductibles and co-payments? What is the annual out-of-pocket limit (the amount that you must pay before insurance pays 100 percent)?

Are there services that are excluded from being covered? This is particularly important if you have a certain service that you need on a regular basis, such as speech therapy.

What is the lifetime benefit limit? This is the maximum dollar amount that the policy will pay for medical claims for a person before coverage runs out. This amount accumulates over time and is generally between $500,000 and $2 million. Once the maximum is reached, the insurance company will no longer cover the individual.

Are there any annual benefit limits? An annual benefit limit is the maximum dollar amount provided for a specific service. For example, there may be a limit of $500 for physical therapy sessions within a 12-month period.

Are there any exclusion riders or waivers? Individual policies may have amendments (riders) that permanently exclude coverage of medical problems related to specific conditions.

Are children who are adults with disabilities covered? Most group policies for family members stop covering children once they reach 18 or 21, but if the child is diagnosed with mental retardation or a developmental disability, the coverage may be continued for as long as the child continues to depend on the family for care and support.

Pre-Existing Condition Restriction. Insurance companies may have a pre-existing restriction in their policy, but the company must follow individual state rules when enforcing the restriction. First, there is the "6 months look-back" which is when the policy can limit or exclude coverage for any condition that had been treated or diagnosed in the six months before you applied for the new policy. Second, there is the "12 months wait" which is when the company can make you wait up to 12 months before it will cover the pre-existing condition.

There are exceptions to these two rules. If you or someone in your family has a pre-existing condition be sure you understand the rules in your state and with the insurance carrier.