Whether you are selecting a health care insurance plan or are already enrolled in a plan, the time to consider if it will provide you with the best possible medical care is before you need to use it.

Now is the time to get important information about your choice of physician, medical coverage, costs and quality. Here are some typical incidents and some questions that might arise.

The Scenario:

Years ago, you were in a car crash, resulting in a broken leg and hip. Under the care of an orthopaedic surgeon, you recovered and returned to normal daily activity.

The Problem:

Lately, you're having some pain in your knee and want to see the same orthopaedic surgeon, but your health plan doctor will not refer you.

• Can you see your orthopaedic surgeon ?
• Is your orthopaedic surgeon part of your health plan?
• Does the insurance company offer a point-of-service plan that allows you to see a specialist when you believe it is necessary?
• If you want to see a doctor not listed in the plan, will the plan pay part of the cost? If so, how much?
• Will the insurance plan doctor refer you to an orthopaedic surgeon for treatment or just for consultation?
• Is there a "gag" clause that limits what you can be told?

The Scenario:

Your child falls while playing. You think his arm is broken and rush to the hospital emergency room.

The Problem:

You learn that the managed care plan will not pay for emergency treatment unless you see the plan's doctor first. At the doctor's office you are told to go to another office several blocks away to get an X-ray of the arm because your health care plan will not allow you to get X-rays in the doctor's office. Your child's care is delayed for hours.

• Do you need to get approval from the plan to get emergency care for an injury? Who decides if your problem is an emergency?
• Is the plan's doctor and hospital located nearby?
• Can you get X-rays and other treatments in your doctor's office or must you go somewhere else?
• Can you see an orthopaedic surgeon in an emergency?
• What is the procedure for admission to a hospital?

The Scenario:

Your employer changes the company's managed care plan.

The Problem:

When you ask to see a doctor about a pain in your knee that was treated six months ago under the previous plan, you are told it is a pre-existing condition. You'll have to pay for the examination and for the physical therapy and a brace.

• Are pre-existing conditions covered and, if not, when is a problem called pre-existing?
• Is there a waiting period to get a pre-existing condition covered for treatment? How long is the period?
• What types of splints, braces, and crutches are covered benefits and for what conditions?
• Does the plan cover physical therapy, home care and other services?
• Does the plan impose a limit on how much it will pay for a specific illness or injury?
• Does the plan limit some forms of treatment?
• Are the medicines you receive limited to those listed by the plan or can your doctor prescribe the drug that he or she thinks you need?
• Does the health plan limit how much it will pay for drugs?

The Scenario:

You injure your knee on a vacation in another city and you're treated in a hospital there.

The Problem:

Instead of paying your usual co-payment fee, your managed care insurance plan requires you to pay the entire bill because you went "outside the plan." If your doctor decides you need physical therapy, will your plan pay for it?

• How much do you have to pay for the health care you receive when you are out of town?
• How much do you have to pay for emergency care?
• How much is the co-payment for each visit?
• What is the premium per month?
• Is there a deductible you will have to pay per year?
• Will the plan pay for your visits to your orthopaedic surgeon?
• Does the plan "charge" your family doctor if he or she sends you to see your orthopaedic surgeon? Is he or she paid more if you get less care?
• Will the plan pay for tests and procedures your doctor believes you need, such as an MRI?

The Scenario:

Your employer has selected a new health care plan for you and your family.

The Problem:

You hear conflicting views from friends and relatives about the plan.

• Does the plan have a "report card" for the care it provides?
• Is there a "report card" for your doctor? Can you see it?
• Are the doctors in the plan board-certified?
• Does your plan keep patient satisfaction surveys? Can you see them?
• Does the plan have a good reputation with patients in the community?
• Is your doctor satisfied with the level of care that the managed care plan allows?

You will get the health care you need only if you are informed about your choices. Even if your employer selected the plan, it is your responsibility to find out what the plan will do for you.

Your orthopaedic surgeon can help you get the quality medical care you need. A health insurance plan may have limits that your orthopaedic surgeon cannot change, but he or she still will be your advocate for quality health care.

Your managed care plan should provide you with timely information about what is covered and how to get the care you need. You should find out the following information about your plan.

• Has the plan designated someone to answer your questions? (name)
• Is there a specific telephone number to call to get information? (number)
• Who can you contact at your company to talk about your managed care plan? (name)
• What is the process to appeal a decision made by the insurance plan?
• Can your orthopaedic surgeon appeal a plan's decision in order to help you get care he or she thinks you need? Will your orthopaedic surgeon be penalized if he or she helps you?
• How can you get a second opinion outside the plan? How much of the cost will your plan pay?

The National Committee for Quality Assurance (NCQA) accredits health plans, based on an assessment of 50 quality standards. NCQA will provide a free list of the more than 200 health plans that have been accredited. Call 1-800-839-6487.