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How to Use and Manage Your Health Insurance Plan

Health Insurance Guide

Health Insurance Plan Health Care Plan Policies Benefits Coverage Doctors Hospitals Emergencies

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How to Get the Most from Your Health Insurance Plan
You will get the best care if you:

  • Stay informed; read your health insurance policy and member handbook. Make sure you understand them, especially the information on health care benefits, coverage, and limits. Sales materials or health insurance plan summaries cannot give you the full picture.

  • See if your health insurance plan has a magazine or newsletter. It can be a good source of information on how the health care plan works and on important policies that affect your care.

  • Talk to your health benefits officer at work to learn more about your health insurance policy.

  • Ask how the health insurance plan will notify you of changes in the network of providers or covered services while you are part of the health care plan.

Take Charge of Your Own Health Care

  • 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 health care questions and insist on clear answers.

  • Ask about the risks and benefits of health and medical tests and treatments. Tell your doctor what you like and dislike about your choices for health 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 understand things.

Keep Health Records

  • 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 health care. Include health histories of shots, illnesses, treatments, and hospital visits. Ask for copies of medical 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.

Get Health Care When You Need It

Learn how your health coverage works and what you can expect from your health insurance plan, doctors, and other health care providers. These are key steps to getting the health care you need. Ask these questions:

  • When is the doctor's office open? What if I need medical or health care after hours?

  • How do I make doctor appointments? How quickly can I expect to be seen for illness or for routine health care?

  • If I need medical 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 health care as well?

  • Is there a medical or health care advice hotline? Some health insurance plans have toll-free phone services that help members decide how to handle a health problem that may not require a doctor's visit.

Find out how your health insurance plan provides health care outside the service area and what you must do to get that care. This is especially important if you travel often, are away from home for long periods, or have family members away at school.

If You Have to Go to the Hospital

The time to find out what rules your health insurance plan has on hospital care is before you need it.

Planned Hospitalizations
Unless it is a medical emergency, your health insurance plan or primary care doctor will probably have to give advance approval (pre-admission 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 health insurance plan network?

  • Is there a limit on how long I can stay in the hospital?

  • Who decides when I am to be discharged from the hospital?

  • Will needed follow up care, such as nursing home or home health care, be covered by the health insurance plan?

  • If I have a serious medical problem, will the health plan provide someone to oversee my health care and make sure my needs are met?

  • Ask how your health insurance plan handles getting a second doctor's opinion on whether surgery or another medical 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 kinds of medical problems are defined as emergencies and how to arrange for ambulance service, if needed. Most health insurance plans must be told within a certain time after emergency admission to a hospital. If the hospital is not part of the health insurance plan network, you may be transferred to a network hospital when your condition is stable. Ask these questions:

  • How does the health insurance plan define "emergency care?" What conditions or injuries are considered emergencies?

  • How does the health plan handle "urgent care" after normal business hours?

  • How do I get urgent care or hospital care if I am out of the area?

  • How do I let the health insurance plan know, and how soon after I get the care?

"Urgent care" is for problems that are not true emergencies but still need quick medical attention. Check with your health insurance 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 health plan may also have urgent care centers for members.

If You Are Dissatisfied with Your Health Care

Getting the best health care and services means understanding how your health insurance 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 health insurance plans during open enrollment.

Most health insurance plans have an appeals process that both you and your doctor may use if you disagree with the health plan's decisions. If your health care 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 health insurance plan for more information or to complain. Use your health plan's complaint process fully before taking other action. Be sure to keep written records of:

  • All correspondence with the health insurance plan

  • Health insurance claims forms and copies of bills

  • Phone conversations: the date and time, the people you speak with, and the nature of each call
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