Getting the Most Out Your Health Insurance
Stay
Informed
- Read your health insurance policy
and member handbook. Make sure you understand them, especially the
information on benefits, coverage, and limits. Sales materials or plan
summaries cannot give you the full picture.
- See if your plan has a magazine or
newsletter. It can be a good source of information on how the plan works and
on important policies that affect your care.
- Talk to your health benefits
officer at work to learn more about your policy.
- Ask how the plan will notify you
of changes in the network of providers or covered services while you are
part of the plan.
Take
Charge
- Ask your doctor about regular
screenings to check your health. Discuss your risk of getting certain
conditions. What lifestyle choices and changes might you need to make to
lower your risks or prevent illness?
- Ask questions and insist on clear
answers.
- Ask about the risks and benefits
of tests and treatments. Tell your doctor what you like and dislike about
your choices for care.
- Make sure you understand and can
follow the doctor's instructions. You may want to bring another person along
or take notes to help you remember things.
Keep
Track
- Write down your concerns. Start a
health log of symptoms to help you better explain any health problems when
you meet with your doctor.
- Set up health files for family
members at home. This will help you to monitor care. Include health
histories of shots, illnesses, treatments, and hospital visits.
- Ask for
copies of lab results. Keep a list of your medicines, noting side effects
and other problems (such as other drugs and foods that should not be taken
at the same time).
How Do I Obtain Care?
Learning
what you can expect from your health plan and how it works are key steps to
getting the care you need. Ask these questions:
- When are the offices open? What if
I need care after hours?
- How do I make appointments? How
quickly can I expect to be seen for illness or for routine care?
- If I need lab tests, are they done
in the doctor's office or will I be sent to a laboratory?
- Will most of my appointments be
with the primary care doctor? Will nurse practitioners or physician's
assistants sometimes give care as well?
- Is there an advice hotline? Some
plans have toll-free phone services that help members decide how to handle a
problem that may not require a doctor's visit.
- Find
out how your plan provides care outside the service area and what you must do to
get care. This is especially important if you travel often, are away from home
for long periods, or have family members away at school.
What if I Have to Go to the Hospital?
The
time to find out what rules your plan has on hospital care is before you need
it.
Planned
Hospitalizations
Unless
it is a medical emergency, your health plan or primary care doctor will probably
have to give advance approval (preadmission certification) for you to go to the
hospital. Otherwise, the cost of your hospital care may not be covered. Ask
these questions:
- What hospitals are part of the
plan network?
- Is there a limit on how long I can
stay in the hospital?
- Who decides when I am to be
discharged?
- Will needed follow-up care, such
as nursing home or home health care, be covered by the plan?
- If I have a serious medical
problem, will the plan provide someone to oversee care and make sure my
needs are met?
Ask
how your plan handles getting a second doctor's opinion on whether surgery or
another treatment is needed. Are second opinions encouraged or required? Who
pays?
Emergency
or Urgent Care
If
you have a true medical emergency, you should go to the nearest hospital as fast
as possible. It is important for you to know what kind of medical problems are
defined as emergencies and how to arrange for ambulance service, if needed. Most
plans must be told within a certain time after emergency admission to a
hospital. If the hospital is not part of the plan network, you may be
transferred to a network hospital when your condition is stable. Ask these
questions:
- How does the plan define
"emergency care?" What conditions or injuries are considered
emergencies?
- How does the plan handle
"urgent care" after normal business hours? Urgent care is for
problems that are not true emergencies but still need quick medical
attention. Check with your plan to find out what it considers to be urgent
care. Examples may include sore throats with fever, ear infections, and
serious sprains. Call your primary care doctor or the plan's hotline for
advice about what to do. The plan may also have urgent care centers for
members.
- How do I get urgent care or
hospital care if I am out of the area? How must I tell the plan and how soon
after I get the care?
What if I Am Not Satisfied with My Care?
Getting
the best care and services means understanding how your health plan works, what
your rights are, and how to complain if you need to. You have the right to get
copies of test results as well as medical information about yourself. If you are
in a managed care plan, you can ask to change your primary care doctor if you
are unhappy with the relationship. You may also be able to switch plans during
open enrollment.
Most
plans have an appeals process that both you and your doctor may use if you
disagree with the plan's decisions. If your plan refuses to provide or pay for
services, you can complain or file a grievance about any decision you feel is
unfair—or you can appeal it.
You
can contact the member services division of your plan for more information or to
complain. Use your plan's complaint process fully before taking other action.
Be
sure to keep written records of:
- All correspondence with the plan.
- Claims forms and copies of bills.
- Phone conversations—the date and
time, the people you speak with, and the nature of each call.
If
the plan does not satisfy you, you may decide to bring the matter to the
attention of your employee benefits manager, your state insurance commissioner,
your state department of health, or the legal system. If you are a Medicare or
Medicaid beneficiary, you have additional ways through those programs to file a
grievance about the care received from a plan or provider. For information,
contact your state's medical Peer Review Organization or state Medicaid Program.
************************************************************************************************************
Choosing
and Using a Health Plan. AHCPR Publication No. 97-0011, March 1997. Agency for
Health Care Policy and Research, Rockville, MD, and the Health Insurance
Association of America, Washington, DC.
- Works by the U. S.
Government are not eligible for U. S. copyright protection.
Other Helpful Things to Keep in
Mind
- Not all plans cover routine exams or preventive care such as physicals or
check-ups.
- Prescription drug benefits vary from plan to plan. With some companies you
have to "purchase" the drug benefit separately.
- Check to see if a drug formulary is used. Some plans use a drug formulary
list to determine which drugs are covered or they offer a greater benefit
level for drugs on the list. An extensive formulary list is more likely to
provide you the greatest prescription benefit.
- Many plans require that you use a preferred network of providers to
receive their highest level of benefits. Check to see that your providers are
in their network before you apply for coverage. If you are unwilling or unable
to change providers you should look at another health plan.
- There are four basic types of health insurance products.
See
FAQ
for Individuals
for definitions of
PPO - Preferred
Provider
Organization HMO- Health Maintenance
Organization
POS - Point of
Service and Fee-for-service
plans, which
are also called Indemnity plans or Traditional Plans.
Information provide here is
for general informational purposes and is not intended to be personalized advice.
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