For years, I have been working with companies and their benefits plans. Two things are certain: I am grateful that I have a good grasp on how health plans work, and most plans are not easy to understand. U.S. health privacy laws make it difficult for people to intervene on your behalf without written permission (see tip 10 below). As our healthcare system continues to become more complex, here are some handy tips based on the most common issues HR professionals encounter:
1. Not all plans are created equal. Just because a procedure or prescription was covered on one plan, does not mean it will be covered on another (even within the same carrier). Always double-check.
2. Always check that your doctor is "in network." Do not call the doctor's office and ask if they take the insurance. The answer to that question is likely "yes." Instead, ask if they are "in network" and make sure you know the name of your network when you call.
3. If you go out-of-network, be prepared to pay a lot more out-of-pocket. Insurance companies negotiate rates for patients that use out-of-network doctors. While the plan may say 70 percent of costs are covered, normally the plan will only cover 70 percent of those negotiated rates. This will make you responsible for the difference between the actual costs and the negotiated rate. Don't ignore this -- potentially expensive -- difference spelled out in the fine-print.
4. If you are having any procedure, call the doctor's office and ask for the billing code. Armed with that code, call your insurance carrier and ask them how and under what circumstances those codes are covered. Once, I found that a procedure I was having was only covered under certain circumstances. Thankfully, my case for the procedure was covered. Knowing this, I made sure my doctor made note of the covered circumstances when processing the billing, so it was covered without hassle.
5. If you are having a major procedure, it often requires pre-authorization. Make sure to get that pre-authorization, so you don't end up paying out of pocket for missing that step.
6. While your health insurance coverage typically starts immediately once you begin a new job, you will never have your insurance cards on day one. Issuing the cards typically takes a few weeks. Luckily, many carriers offer temporary insurance cards. In the interim, you have options: Wait for an appointment (if it is not urgent), have your doctor hold off on billing until you have your information or pay out of pocket at the time of service and submit a claim for reimbursement later.
7. Most insurance companies will give you the generic medication of your prescription. If for some reason you need to take the name brand, you must have your doctor state that on the prescription.
8. If you use a Flexible Spending Account (FSA), plan carefully. These plans are "use it or lose it." There is a new rule that allows you to carry over $500, however this can only be used if your plan does not allow for a 2.5 month grace-period. It is one or the other, so check carefully which rule applies. Similarly to tip one above, if you change jobs, your new employer may handle this differently, than your previous one.
9. If you are traveling overseas, know how your plan works in the event you get injured or need to be hospitalized. There may be paperwork you can carry to help expedite the process.
10. If you become very ill and think you may not be able to keep up with your medical bills or required documentation, consider designating someone to have access to your personal health information (PHI). This is typically referred to as a HIPAA authorization allowing someone to act on your behalf. Otherwise, it can be very difficult for a family member or friend to assist in communications with your insurance carrier on your behalf due to health privacy laws.
While this is not an exhaustive list, it should provide you a solid foundation for taking your healthcare into your own hands and avoiding unnecessary frustration.