Understanding Your Health Care Benefits

You know you have health insurance, but you just don't know what that means or what your plan includes. You know you signed some health insurance forms when you became eligible with your current employer and that's the last consideration you've given it. Until now; now you need to go to the doctor and you're wondering what your health insurance covers.

Know What Your Health Insurance Coverage Includes

Recently, a friend told me of a woman facing breast cancer surgery. In speaking with the care givers at her surgical center she was informed that because she has an HMO (health maintenance organization) plan her health insurance would only cover one and one-half days stay in a hospital room after the surgery was complete. Realizing this was insufficient time to recuperate, she was quite naturally upset.

When she called and spoke with her health insurance carrier she found out that the surgical center was incorrect in their information and her health insurance covered her for unlimited days of hospital stay. Why the discrepancy?

As disheartening as this may sound, the most likely underlying factor is money. In the world of the HMO there is something called capitation. Capitation is a fixed fee that is paid annually to a physician or medical group for each member in the health plan who they service regardless of the number of visits that member makes; so less visits, less work and more financial gain. On the other hand, members who see their doctors frequently or even regularly nibble away at the set fee a doctor receives each year resulting in less golf time, more patient time and lower overall income.

Unfortunately, the surgical center was likely attempting to lower their costs/increase their revenue by getting this young woman in and out as quickly as possible. Fortunately for the young woman she found out what she needed to know prior to her surgery date.

It is your responsibility for understanding your health insurance benefits. After all, you (and your employer) are paying for them, so know what you are getting. That means reviewing your evidence of coverage (EOC).

The EOC is the document that you received when you signed up for health insurance and which most health insurance carriers make available to their members on line. Generally, you'll just need to sign in to gain access and then you can search for information regarding the types of procedures your plan covers along with information about the cost to you (also known as the co-payment).

Take Responsibility for Your Health and Your Health Insurance

Without sounding preachy, only you can take care of your health. Naturally that means eating right and getting plenty of exercise and rest. In addition, it is important to understand what preventative services your health insurance offers. Check to see if your plan covers things such as annual physical exams, routine eye and hearing tests, colonoscopies, and other important preventive health care procedures. And stay in contact with your doctor.

If you change medical plans and/or medical groups which results in a new primary care physician, make an appointment for a checkup and to introduce yourself. Then be sure to stay in touch at least annually (say, for a physical). Physicians leave medical groups, change practices and even drop inactive patients, so it's important to stay aware of who is providing your care.

Personally, I unexpectedly changed gynecologists a few years ago when I showed up for my appointment and found my regular physician had left the practice. They had moved my appointment to another female doctor, which ended up working out just fine. But I was surprised to say the least.

Next, make sure you understand how your health care plan works. Last year my mother-in-law became quite ill while visiting us and ended up in the hospital. When a bill arrived for thousands of dollars, she was distraught. Until I reminded her she had health insurance and that we should contact the insurance carrier and make sure they would handle it. We did and were promptly informed that they had received the same bill which was currently being processed for payment. Why two bills?

More than likely to cover themselves in case the health insurance carrier declined to pay, though I have friends who indicate they think it's the providers way of trying to double dip or get two payments for one service. Truth is many people will pay a medical bill without asking questions or be intimidated into paying for services which are covered under their policy. That's why it's important that you take responsibility for your care and your coverage.

This means when you first receive your health insurance card, review it for accuracy. Does it have the right doctor's name and medical group on it? Is your name spelled correctly? Also make sure to keep it with you at all times. It makes no sense to go to a doctor's appointment without your health insurance card and have to call your health insurance carrier to get the information before you can see your doctor. And heaven forbid if you unexpectedly become ill or are injured and need to rush to the emergency room. Your health insurance card should be on you at all times along with your photo I.D.

Now having said all this keep in mind that your health insurance company cannot fix all your health care problems. Take for instance the story of an elderly man who sat in the doctor's waiting room for several hours without receiving service. Instead of following up with the receptionist to find out what was taking so long, he called his health insurance company to complain. It's important to take the time to understand what your health insurance company can and can't do for you.

Whatever health care plan you may have be sure to review and understand it. And if you have any questions, instead of asking your doctor, the medical center staff or hospital personnel, contact the member services department of your health insurance company. They provide your insurance coverage and are the best equipped to provide accurate information.