This is part 2 of a 2 part series. To see part 1, click here.
After determining the costs associated with a health insurance policy (see “Got Health Insurance: Questions to Ask to Understand Coverage Cost”) the next step is to determine what services are covered in the plans. To help you analyze the benefit details, read the questions below and make a list of coverage that you might need in the coming year (i.e. preventive care, prescription drug coverage, emergency care, out-of-network, etc). This will help you reduce the anxiety associated with the amount of information generally provided in the plan detail.
Remember to take good notes for comparing plans. If you cannot find an answer or something seems confusing call your insurance company.
- How does the plan treat preventive exams and health screenings? Under Health Care Reform, preventative care will be covered. Be aware of how the insurance company defines “preventative care” and what is included.
- What prescription coverage does the plan provide? Many plans cover generic and brand-name drugs differently. Many insurance companies provide a list of covered prescriptions and approximate costs for each drug plan. Look carefully at the coverage and cost details for medications, as these can become a significant (and unanticipated) monthly expense.
- Does the plan require referrals to see specialists? Referrals are a transfer of your medical care from one doctor to another, usually from a general primary care physician to a specialist. For example, if you are having serious stomach pain, your general physician might refer you to an internist. If referrals are required, failure to get one can delay care or increase cost. Examine charges for specialist visits and treatment, since these often differ from routine care coverage and costs. If you know you will be seeing a specialist in the coming year look for preferred provider organization (PPO) polices or a plan that specifies “no referrals required” in the plan details.
- How does the plan cover emergency care? Determine if emergency care is subject to a copay or coinsurance. Also, compare the cost differences between urgent and emergency care. For information on the difference between Urgent Care and Emergency Care, see Urgent Care Versus Emergency Rooms.
- Does the plan have coverage for vision and dental care? The range of coverage and benefits for vision and dental can vary widely, or be a supplemental option. Be sure to take note of it, as dental care is a vital part of general health and vision emergencies can occur, even if your eyesight does not need correction.
- Does the plan cover hospital, in-home, and nursing home care? Get a clear idea on what services the plans cover for hospital, in-home and nursing home care and the associated costs (copays vs. coinsurance). Also, know whether the plan puts a limit on maximum coverage for any of these. Nursing home care is not included as an Essential Health Benefit.
- What coverage does the plan provide for rehabilitation and physical therapy? Recovering from illness, an accident, or surgery may necessitate physical therapy or rehabilitation. It’s best to know beforehand how a plan covers these. Many plans limit the dollar amount or number of visits and may require pre-authorization.
- Does the plan have provisions for behavioral and mental health? Mental Health Disorder care is an Essential Health Benefit under the ACA, make sure to understand what is and is not included for your specific plan.
- What about alternative therapies/treatments? Alternative treatments like holistic medicine or acupuncture are increasingly popular. Some may qualify for coverage in some health insurance plans.
- Is a preferred provider/doctor in-network? Health insurers contract with physicians and facilities that are “in network,” typically negotiating lower rates. Look to see if a favorite provider or facility is in-network. Most insurers provide information on in-network doctors and facilities on their website. You can also call your doctor’s office or the insurance company to ask.
- One question people soon won’t face: annual and lifetime maximum coverage limits. Health care reform prohibits these financial “caps” beginning on January 1, 2014.
While the Affordable Care Act will expand access to health insurance, coverage details can be confusing. Ask questions about every health insurance option to be sure the plan, the financial commitments, and the coverage are clear. Stay well.
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