Check health-care coverage before crisis

Several weeks ago, my husband and I learned that our daughter Olivia had developed a rare condition brought on by juvenile rheumatoid arthritis.

Our 7-year-old could die if her physicians can’t stop cells known as macrophages from attacking and destroying her red and white blood cells. Essentially, Olivia’s immune system is attacking her own body.

It wasn’t until that moment in a staff room at Children’s National Medical Center in Washington when I found out the gravity of Olivia’s condition that I fully appreciated how fortunate I was to have a good job. Without my job, I wouldn’t have access to the kind of health insurance it is going to take to treat my daughter’s illness.

I can’t help but wonder how much more scared and stressed I would be if I didn’t have adequate medical coverage.

I chose my plan, Kaiser Permanente, like I picked my bank. The HMO was convenient. It had a large medical center near my home.

Sure, I had looked at the type of coverage the plan offered and what co-payment would be required compared with other plans available through my company. But there was so much I didn’t check out.

“Which health plan you choose can have important consequences for the quality of health care you get, the convenience of getting that care, the ease and pleasantness of dealing with the plan, and your total health care costs,” say the editors of Consumers’ Checkbook, an independent, nonprofit consumer and information service.

About the same time Olivia was admitted to the hospital, I received Consumers’ Checkbook’s “Guide to Health Plans.” The $14.95 publication is full of important and potentially life-saving advice. It can be ordered with a major credit card by calling (800) 213-7283 or on the Internet at www.checkbook.org.

Here are some key things to do or ask, according to Consumers’ Checkbook and other experts:

Find a good primary-care physician. This “is essential to getting good care in any type of plan but especially critical in an HMO, where this doctor will be the gatekeeper controlling access to all other services,” according to the health plan guide.

Understand how to get a referral for specialty services. This is why you want to select not just a good doctor, but one who is good at navigating your plan’s referral system.

Find out who authorizes what treatment you will need during a hospitalization. By far the best thing I think Kaiser has done is station one of its own physicians at Children’s. That doctor has been a godsend. He coordinates daily with the wonderful team of physicians assigned to Olivia. He works for Kaiser but he’s become our doctor, our advocate and now our friend.

Find out which services are covered and what limitations and exclusions there are. You might be surprised to find out that your policy has what is called a lifetime limit, which is sort of like a credit-card limit. It establishes a monetary ceiling for how much you will be covered for the life of your policy. Data from the Kaiser Family Foundation show that the lifetime limit often depends on the size of the company you work for. The larger the company, generally the higher the lifetime limit. Overall, says the foundation, 63 percent of employer-based health insurance plans carry a lifetime limit of $1 million or more in maximum value; 21 percent carry no maximum value and 6 percent carry a limit of $1 million or less.