- 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 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 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 plan.
Taking
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
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 understand things.
Keeping
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 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
to Get Care When You Need It
Learning
what you can expect from your health insurance 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 health insurance 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 health insurance 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 You 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 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?
- 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 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 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 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 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 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 plan may also
have urgent care centers for members.
What
If You Are Dissatisfied with Your Care?
Getting
the best 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 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 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.
 
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