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The Rules of Your Plan

For the remainder of the summer, we will be reposting educational material on Health Insurance Basics which was originally aired in 2021, with updated 2022 information as appropriate. If you didn’t watch these videos, please do, and tune back in after Labor Day for new material. Thanks, and have a wonderful summer.

Today’s featured topic is about the rules of one’s Plan. Please watch the video at healthcarenavigation.com/videos and spread the word so that others learn about this important topic.

All coverage has rules one must follow in order for claims to be paid. The more restrictive plans have more rules so be particularly mindful of them if you are enrolled in a Health Maintenance Organization (HMO) or Exclusive Provider Organization (EPO) product.

The following are rules to understand:

Primary Care Physician (PCP): Know if your Plan requires you to have a PCP which is an in-network internist, family practitioner or, sometimes, an Ob-Gyn physician, you have elected.

Referral: Know if your Plan requires a referral from your primary care physician in order for you to see a specialist. If you are enrolled in what is called an Open Access Plan, you do not need a referral.

Prior Authorization: All Plans require prior authorization, sometimes referred to as precertification, for various expensive services including expensive drugs and procedures. It is the in-network provider’s responsibility to obtain prior authorization for in-network services. If you see an out-of-network provider, you need their cooperation to obtain prior authorization since they need to initiate the process but you have a greater responsibility to “make it happen.”

The justification for prior authorization is reasonable since its purpose is to require additional scrutiny for expensive medical procedures. However, the current state of affairs is entirely unacceptable from both the patient and provider perspective.

Claims Filing Deadline: If you have out-of-network benefits you may have to file claims with the insurer. There is always a claim filing deadline beyond which the insurer does not have an obligation to pay the claim. Know what the deadline is and file claims comfortably in advance of the deadline.

Notification to Plan of Emergency Hospital Admission: Many Plans have language that requires you to report an out-of-network hospital admission within 48 hours.

How to Find the Rules of your Plan

Most of the information required to understand your Plan’s rules is on your insurer’s portal when you log in to your account. But some websites are better than others.

In sum, in today’s adversarial healthcare climate, the burden is often on the patient to know the rules of the Plan even when the details seem shrouded in secrecy. If you have questions, call customer service and be conscientious, persistent and keep good records.

Please watch the video and consider “liking” it. We would also love to hear your comments.