What to ask to select best insurance plan

What do you need to know to get the best insurance deal you can in a tough year?

Plenty. And to bring out your Inner Informed Consumer, the first order of business is to ask questions, read the information you get carefully and know your rights.

But first, be prepared for this:

You'll probably have to make hard choices about your coverage priorities: Is it crucial that prescription medications are fully covered? Could you live with a large deductible? Do you insist on seeing specialists of your choice?

If you're a member of an employer group, you should be able to inspect a booklet describing the plan's coverage. See our resources list below for other helpful sources.

And here are some questions experts suggest can help produce the answers you need:

Q: Are the doctors listed in the plan really available?

A: Turnover is a concern to many who work hard to find a doctor whose style, expertise and availability meshes with their needs.

Finding a meaningful way to compare turnover in plans is tough. Instead, try these questions:

What percentage of your locale's doctors is signed up with the plan? Is your doctor signed up? And: Are they planning to stay that way?

Don't assume that the printed list the health plan offered you is up to date. Go to the plan's Web site and check the updated list. Then call the health-care provider's office to ask: Are you having any problems? Thinking of leaving?

If you're looking at new doctors, ask: Are they accepting new patients?

Q: What are the deductibles and co-payments, for office and hospital care and for prescription drugs?

A: Many people have seen "co-payment creep" already, and many plans will again be increasing your share of the costs this year.

Consider: For prescription drugs, must you pay a lot to get the ones you want? Does your plan require you to use mail-order pharmacies to get the best coverage? If there's a tiered approach that covers only generic drugs at the best rates, could you switch medications? This might involve a call to your doctor before you decide on a plan.

Figure out where you're really going to pay money out of pocket. For example, if you're young and healthy and have cash available for what you expect to be minimal health expenses, it may make sense to have a plan with a high deductible and a low premium. But typically such plans have no prescription drug coverage, so, if, for example, you have asthma that takes a healthy chunk of change to keep controlled, that plan may not be for you.

Q: Does the plan exclude the care you want?

A: Take a careful look at the "exclusions" section, and think about what kind of care you're likely to want. Does the plan cover mental health? Chiropractic? Childbirth? If you travel a lot, under what circumstances will your plan pay for care outside its service area?

Q: What are the plans' maximums?

A: Plans frequently set dollar or visit maximums for different categories of care, such as mental-health care, so don't stop with simply ascertaining that a procedure or illness is covered.

Q: What's this I hear about "usual, customary and reasonable" charges?

A: It means that sure, your plan pays for a wart removal, but it considers the "usual, customary and reasonable" charge for the procedure to be about half of what your doctor billed you for.

In this state, participating providers with HMOs and health-insurance companies are barred by law from billing you for the part of the bill your plan didn't pay — the balance.

But if you go outside the network, all bets are off. Or if your plan has you paying a percentage of the bill. Most plans will give you a ballpark idea; exact rates negotiated with physicians are proprietary information. You'll likely get the best information from your doctor.

Q: Is the company user-friendly?

A: Many companies are recognizing that it pays to answer consumers' questions quickly and clearly; others have been slow to get the message. Call customer service; go to their Web site. Look at surveys of consumer satisfaction. Regence BlueShield, for example, has developed a plain-language online User's Guide at www.wa.regence.com/guide. An "Insurance to English" feature translates jargon.

— Sources: The state Office of the Insurance Commissioner; Regence BlueShield; health-care attorney Jeffrey Coopersmith.

Carol M. Ostrom: 206-464-2249 or costrom@seattletimes.com.