Understanding Your Health Insurance Plan

Health insurance policies are complex and often very difficult to understand. However, it is important to be very clear about what your policy covers, what it does not, and how to appeal denials. Many plans make determinations of what they will cover based on "medical necessity." Appeals usually center around a difference of opinion between the physician or provider of care and the insurance company as to what intervention or treatment is medically necessary.

Most health plans today incorporate managed care to a varying degree. This means there will probably be some level of incentive and financial benefit for enrollees to use the particular network of providers associated with the plan. It is therefore important to review a plan's list of providers to see if specialists are included who are appropriate to your medical needs, and whether doctors with whom you have an established relationship are included in the plan.

The "Summary of Benefits" you receive when you enroll in a health plan is not a legal document. It is just what it says—a summary. Request the "Evidence of Coverage" document from your plan so that you have the exact details of your policy.

When reviewing your policy, pay particular attention to the following:

• Open versus restricted network of providers

• Required preauthorizations

• Access to specialists

• Coverage for hospitalization, major medical, and prescription drugs, particularly any MS treatments that are prescribed for you

• Amount of co-insurance, co-pays, and deductibles

• Pre-existing medical condition waiting periods

• Out-of-pocket maximums

• Levels of coverage for physical therapy, psychotherapy, rehabilitation, equipment, and home healthcare

• Specific coverage limitations and exclusions

• Yearly/lifetime maximums of coverage

• Options and procedures for appeal

If you find yourself in the position of having to select from a choice of plans, which is increasingly the case when select ing employer coverage these days, review each plan available to you using the above criteria in order to be sure you are selecting the plan most appropriate for you in terms of your particular medical concerns.

If you are applying for coverage, and you are asked questions about your health status, it is important that you not lie on the application and intentionally hide the fact that you have MS. You must respond honestly and fully to any question. However, you do not have to volunteer any information that is not requested directly or by implication.

0 0

Post a comment