Preventing health insurance mishaps by knowing how you’re covered
THERE’S NO GETTING around the fact that healthcare insurance plans can be complicated and confusing. There are many different types of plans, such as managed-care plans, and each has its own set of rules and requirements. However, having the right information — down to the smallest details — about your managed-care plan means that you can make better choices and more informed decisions about your health care.
All signs point to the fact that when you get involved with managing your own health — and that includes your healthcare insurance plan — your health and wellness increase exponentially. Additionally, your wallet will usually benefit a bit as well! Take our quiz on managed-care plans and test your knowledge of health insurance coverage and when to call your healthcare plan provider.
1. Which of the following is a type of managed-care plan?
A. Health Maintenance Organization (HMO)
B. Point of Service Plan (POS)
C. Preferred Provider Organization (PPO)
D. All of the Above
2. Fill in the blank: In managed-care plans, the plan has made contracts with doctors and hospitals, called ________, to offer their services to you at a reduced rate. The entire group of these preferred physicians, hospitals and health groups are called your ________.
3. True or False? Managed-care plans encourage you to see preferred providers in the network, but under an HMO, the plan will NOT pay any portion for services rendered by a non-preferred provider/out-of-network provider; under POS and PPOs, the plan will likely pay only a portion of a medical bill from an out-of-network provider.
4. Under which managed-care plan do you need a referral from your primary care physician/family doctor to see a specialist? (Choose all that apply.)
A. Health Maintenance Organization (HMO)
B. Point of Service Plan (POS)
C. Preferred Provider Organization (PPO)
D. None of the Above
5. What is it called when your health insurance provider must approve expensive services, hospital stays, childbirth, surgery, or certain tests before they are performed or they won’t pay for them at all?
A. Consent
B. Permission
C. Preauthorization
D. Approval
E. None of the Above
6. What is a drug formulary?
A. A tiered list of prescription medications and their corresponding pricing
B. A place where prescriptions are dispensed, like a pharmacy
C. A formula for which prescriptions can be safely mixed and which cannot
D. A specific place where medications are made
7. When should you contact your insurance company?
A. When you have a question about your coverage
B. To ensure a physician, hospital or prescription is in network and/or covered
C. To discuss a bill
D. To get special permission to see a provider outside the network or to get preauthorization
E. All of the Above
8. True or False? Early mornings — especially on Saturdays — are the best time to reach your insurance company by phone with as short a wait time as possible.
9. What’s the best thing to do if the person on the other end of the line at the health insurance company is not answering your question or addressing your concerns to your satisfaction?
A. Give the representative a piece of your mind
B. Calmly ask to speak with a supervisor
C. Hang up and call back to get a different representative
D. Complain to your primary care physician
ANSWERS
1. D. All of the Above. All HMOs, POSs and PPOs are considered managed-care plans.
2. B. Providers; Network. Doctors, hospitals, and the like that are approved by your plan are called preferred providers. All of the preferred providers together are called your network.
3. True.
4. A. HMOs and B. POSs. You must get a referral to see a specialist if you want the insurer to cover the cost.
5. C. Preauthorization. Some insurers include a time component with preauthorization, so read the details of your coverage well.
6. A. A tiered list of prescription medications and their corresponding pricing. Also called a “drug list,” it runs from preferred medications that the insurance company will pay the most for to prescriptions the insurer won’t pay for at all.
7. E. All of the Above. Don’t be afraid to ask for help and clarification.
8. True. According to Bedsider.org, mornings are the slowest times, meaning you’ll get someone on the phone sooner, and the busiest times to try to call is from 11 a.m. to 3 p.m.
9. B. Calmly ask to speak to a supervisor. While it may be frustrating and time-consuming, locating the person who can answer your questions or resolve your issues is well worth it.
CREDIT
article by ERIKA ALDRICH
Resources: Information provided by FamilyDoctor.org and Bedsider.org.