Do you really know what you are getting when you buy health insurance?

Your health insurance policy is an agreement between you and your insurance company. Your policy will list a package of medical benefits such as tests, drugs and treatment services that the insurance company agrees to cover either the partial or full cost of. These are called covered services. Your policy also lists the kinds of services that are not covered by your insurance company. You have to pay for any uncovered medical care that you receive.

When considering policies you must keep in mind that a medical necessity is not the same as a medical benefit. A medical necessity is something that your doctor has decided is necessary while 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.

Your insurance company determines what tests, drugs and services they will cover. These choices are based on their understanding of the kinds of medical care that most patients need. Your insurance company’s choices may mean that the test, drug or service you need isn’t covered by your policy.

Normally your doctor will be familiar with your insurance coverage so he or she can recommend health care that is covered by your current insurance plan. However, there are so many different insurance plans that it’s not possible for your doctor to know the specific details of each plan. By understanding your insurance coverage, you can help your doctor recommend medical care that is covered in your plan.

Take the time to read your insurance policy. It’s better to know 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 your doctor can provide them. If you still have questions about your coverage, call your insurance 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.

While most of the things your doctor recommends will be covered by your health insurance plan, some may not.

If 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. This is often called denying the claim.

You can still obtain 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.

You will get the most from your plan if you:

Stay Informed

* Read your health insurance policy and member handbook. Make sure you understand them, especially the information on benefits, coverage, and limits. Sales materials or plan summaries cannot give you the full picture.

* See if your plan has a magazine or newsletter. It can be a good source of information on how the plan works and on important policies that affect your care.

” Talk to your health benefits officer at work to learn more about your policy.

* Ask how the plan will notify you of changes in the network of providers or covered services while you are part of the plan.

Take Charge

* Ask your doctor about regular screenings to check your health. Discuss your risk of getting certain conditions. What lifestyle choices and changes might you need to make to lower your risks or prevent illness?

* Ask questions and insist on clear answers.

* Ask about the risks and benefits of tests and treatments. Tell your doctor what you like and dislike about your choices for care.

* Make sure you understand and can follow the doctor’s instructions. You may want to bring another person along or take notes to help you remember things.

Keep Track

* Write down your concerns. Start a health log of symptoms to help you better explain any health problems when you meet with your doctor.

* Set up health files for family members at home. This will help you to monitor care. Include health histories of shots, illnesses, treatments, and hospital visits. Ask for copies of lab results. Keep a list of your medicines, noting side effects and other problems.