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Managing your health insurance plan (health plan) can be difficult. Whether you have public health care benefits or private insurance, you need to know how to get the most out of your coverage. This guide will give you general information and tips to help you get the most from your health insurance.

Get to Know How Your Health Plan Works

  • Stay in the network. Most health plans, like HMOs, PPOs, Medicare, and Medicaid, use certain groups of doctors, hospitals, and other healthcare professionals called provider networks. If you visit a doctor outside of your network, you may have to pay more for your care. In some cases, you may have to pay the full cost. If you are referred to a specialist by your primary care physician, make sure they are in your network.
  • Know what’s covered. Make sure services or treatments are covered before you schedule them. Some plans, such as Medicaid or a HMO, require pre-authorization before some services, treatments, and/or tests can be provided.

Where You Go Matters

 It’s important to know where to go when you need medical care. While the answer is not always simple, knowing the difference and deciding where to go can mean the difference in costs and time. The main point is to be prepared before you go and make sure ahead of time you will be covered by your health plan’s network.

  • Health Plan 24/7 Nurse-line – most health plans have a 24 hour, 7 days a week nurse-line (the number can be found on the back of your health plan member services card). Registered nurses are on call to answer your health questions and there is no cost to the member. Be sure to have your member ID card available when calling.
  • Your Doctor – this is your primary doctor for non-emergency care, wellness check-ups, and referrals to specialists. Most doctor offices require an appointment and for most visits there will be a co-pay.
  • Urgent Care – when you need immediate attention (cannot wait a day or two for an appointment) but the issue is not an emergency. Examples of health issues that would be addressed at an urgent care are: headaches, urinary track infection, back paint, cuts, etc. You do not need an appointment at the urgent care and most health plans will have a co-pay.
  • Emergency Room – when you have a life-threatening health issue. Emergency room services are available 24 hours, 7 days a week. You do not need a referral to access an emergency room. Examples of health issues that are best addressed in an emergency room, but are not limited to, are; chest pain, head or neck injuries, fainting, breathing difficulty, etc. Most health plans will have a co-pay for a visit.

Letters of Medical Necessity

 The most common reason a health plan will deny a service is that they do not have enough information about you and your need. To avoid this problem, ask your doctor or health care provider to write a letter of medical necessity and send it with the request for service. The letter should include:

  • Your medical condition with exact diagnosis
  • How long is your condition expected to last
  • Why you need the service/treatment/equipment and a description what is needed
  • What health problems will occur if you don’t get the service
  • What other treatment or services were tried, if any, and why they did not work

Your doctor can ask the health plan to call them with any questions about the letter. Ask your doctor to send the health plan copies of medical records that support their letter of medical necessity.

Decisions on whether a service is medically necessary are usually made by a doctor at the health plan. If your service/treatment/equipment is denied, ask your doctor to call the health plan directly to discuss your condition and needs. If you are still denied, file an appeal. Call customer service on the back of your health insurance card, or follow the instructions on the “Notice of Decision” for filing an appeal. Pay careful attention to timelines, as all appeals have a deadline. When filing the appeal be certain to keep a copy of the appeal request, proof of when and where you sent the appeal (certified mail receipt or fax confirmation sheet).