Family Doctor 2007 - (Page 22) working with your doctor HEALTH INSURANCE Coming to grips with terms in your insurance plan such as “covered services” and “medical necessity” can give you a headache. Read on to clear up the main causes of confusion. By Anne L. Rubeck Health insurance: Are you covered? N avigating the health insurance maze can be confusing and frustrating. There are many types of plans that cover — or don’t cover — a wide variety of health Take time to read through your health insurance policy. your doctor can provide them. This is often the case for more expensive tests like CT and MRI scans, surgery or visits to specialists. ● For some kinds of covered care, there are limits on the number services. How can you be sure of what’s covered by your health insurance policy? Here are the basic areas that a lot of people have questions about. ● Covered services. These are outlined in the package of of treatments that are covered per year. This often applies to mental health treatment as well as physical, occupational or speech therapy. ● If you still have questions about your coverage, call your insur- medical benefits described in your policy. These services can include tests, drugs and various treatments. Your policy also lists the kinds of services that are not covered by your insurance company. As you’ve probably discovered, you have to pay 100% for any uncovered medical care that you receive. You may still have to pay for part of a covered service (called a co-payment) or a percentage of the total cost. ● Medical necessity and medical benefit. A medical ance company and ask a representative to explain it. ● Remember that your insurance company, not your doctor, makes decisions about what will be paid for and what will not. Most of the things your doctor recommends will be covered by your plan, but some may not. When you have a test or treatment that isn’t covered, or you get a prescription filled for a drug that isn’t covered, your insurance company won’t pay the bill. You can still get the treatment your doctor recommended, but you will have to pay for it yourself. If your insurance company denies your claim, you have the right to appeal the decision. Before you decide to appeal, know your insurance company’s appeal process. This should be discussed in your plan handbook. Also, ask your doctor for his or her opinion. If your doctor thinks it’s right to make an appeal, he or she may be able to help you through the process. necessity is not the same as a medical benefit. A medical necessity is determined by your doctor. A medical benefit is something that your insurance plan has agreed to cover. In some cases, your doctor might decide that you need medical care that is not covered by your insurance policy. This is because insurance companies base their policies on what is generally good for most people. Insurers can’t possibly know all the combinations of treatments and services that will be beneficial for each individual. So what should you do to avoid unpleasant surprises? Your doctor will try to be familiar with your insurance coverage so he or she can provide you with covered care. However, there are so many different insurance plans that it’s not possible for him or her to know the specific details of each plan. By understanding your insurance coverage, you can help your doctor choose medical care that is covered in your plan. Consider these tips: ● Take the time to read your insurance policy. It’s better to know Anne L. Rubeck is an editor living in Overland Park, Kan. ADDITIONAL INFORMATION American Academy of Family Physicians http://familydoctor.org/688.xml Centers for Medicare and Medicaid Services http://www.cms.hhs.gov/ Agency for Healthcare Research and Quality http://www.ahrq.gov/consumer/insuranc.htm what your insurance company will pay for before you receive a service, get tested or fill a prescription. Some kinds of care may have to be approved by your insurance company before 22 familydoctor 2007 http://familydoctor.org/688.xml http://www.cms.hhs.gov/ http://www.ahrq.gov/consumer/insuranc.htm
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