FAQs About Health Plan Coverage

How do I know if a certain procedure, surgery or service is covered by my health plan?

Covered benefits typically include medically necessary hospital stays and surgical procedures, diagnostic tests, visits to the doctor and routine preventative care. Some plans include prescription drug coverage. Check with your insurance provider to verify if your plan covers these services.

How do health insurance companies determine if a new medical technology or procedure is covered?

Typically, when medical breakthroughs occur, an insurance company will perform an extensive evaluation to ensure they are appropriate for members. After multiple experts conduct this evaluation, a decision is made whether or not to include the new services in the coverage provided to our members. Coverage for new services may be limited to specific medical conditions, age groups, genders, places, types of service or diagnoses. Speak to a health insurance representative for more information about services that are considered investigational and may not be covered under your plan.

What charges am I responsible for when I receive services?

Depending on your health plan, you may be responsible for a copayment at each visit, an annual deductible, possibly a family deductible, a coinsurance (the percentage of the provider’s bill that you share with the insurer after you have met your deductible), charges for non-covered services or charges in excess of the allowed amount (if you go to a doctor or facility not in your provider’s network). For more information on financial liability, contact your doctor for specific information about your diagnosis and expected procedures, and then ask an insurance representative for information about your plan’s covered services.

Generally, if you are an HMO health plan member and you see an out-of-network physician or specialist without an approved referral from your primary care physician, you will be responsible for all charges except in the event of a medical emergency.

How do I obtain primary care services?

Primary healthcare services, like physical examinations and immunizations, are provided by practitioners who specialize in general medicine, family practice, internal medicine and pediatrics. Primary care services are typically provided in your primary care doctor’s office.

How do I obtain specialty services, behavioral health services or hospital services?

Primary care practitioners can best advice from whom and when to obtain specialty services or behavioral health services, and when and where hospital services should be obtained.

When should I go to an emergency room, urgent care, or other facility for an immediate medical need?

The general rule of thumb for going to an emergency room is if you feel you have a life-threatening injury or illness, or if delaying care puts your health at risk. In these cases, don’t hesitate to go to the ER or call 911 immediately. Unfortunately, people often use the emergency room for conditions that really aren’t emergencies. ERs aren’t designed for this, and the flood of patients without emergency conditions causes long waiting periods and delays in treatment.

For minor injuries or illnesses that are not life-threatening, an urgent care facility is a better choice. Many are open 24/7 or have extended hours. Convenience clinics are also a good option in these cases. These clinics may be located in some drug stores and grocery stores. They are staffed by nurse practitioners or physician’s assistants who can diagnose and treat many illnesses, as well as write prescriptions.

How do I obtain emergency care?

During a medical emergency go to the nearest emergency room or, if necessary, call 911. Contact your doctor within 24 hours of the emergency to arrange follow-up care with one of your insurance company’s network providers.

How do I file a complaint anywhere else about my healthcare?

If applicable to your health plan, you may contact the Department of Insurance for your state. You can find the contact information on your state’s website, under state agencies in your phone book, or by contacting a health insurance representative.

If your complaint is about a denial, reduction or termination of a benefit or service and you continue to disagree with our decision, you have the right to file a complaint with the Department after all appeal rights have been exhausted.

Members of self-insured groups (other than a public employee benefit plan) should not file a complaint with the Department of Insurance. For information about how to file a complaint, contact your employer or group official or contact the U.S. Department of Labor Employee Benefits Security Administration.

Are there options to lower my drug copayment?

Some benefit plans may include a tiered formulary. A formulary is a list of preferred commonly prescribed medications selected by healthcare professionals based on clinical and cost effectiveness. Ask your doctor which medication is best for your condition. With some benefit plans, using products from the formulary can save you money. To request a preferred formulary drug list or to ask a question about your benefits, contact your health insurance representative.

Are there any limitations on medications that my doctor might order?

Some medications may have quantity limits, require prior approval or have other coverage management requirements that must be met before your prescription will be covered. Contact a health insurance representative and ask if your medication is subject to limitations or prior approval requirements. Products that are approved by the U.S. Food and Drug Administration for cosmetic use or weight loss are not covered under most prescription benefit plans.