Obtaining Health Care Through Your Plan
Learning what you can expect from your health plan and how it works are key steps to getting the care you need. Here are some things you may wish to consider or be aware about:
- Make sure you know your physicians office hours and where you need to go for treatment if your doctor's office is closed. Many physicians will work with extended care facilities that charge much less than a visit to the emergency room.
- Many doctors are booked several weeks in advance for routine office visits. Ask your physician how far in advance you need to schedule your appointments. Most doctors' offices will have additional staff or special arrangements for seeing ill patients, but this is not always the case. Find out what your alternatives are if you feel that you need to see a physician but your doctor is unavailable.
- Find out how your physician handles required lab tests. Are these performed in his office, or do you need to travel to a different facility? This may depend on the type of lab work or radiology that is required, but make sure that these procedures are available to you in a convenient location.
- Many doctors will have a staff of physician's assistants to assist him with the demand of many patients. Find out if you will be seeing your doctor or one of his assistants when you make an appointment. If you prefer to be seen by your regular physician, find out when he will be available and schedule your appointments around his availability.
- Find out if your health insurance company provides an advice hotline. Many health plans attempt to lower the cost of medical treatment by providing a 24 hour telephone service that allows you to speak with a physician or nurse. They will help you diagnose your symptoms to determine if a trip to the physician or emergency clinic is reasonable or necessary.
- Find out how your plan handles medical treatments when you are outside of your home state or traveling to another country. This is especially important if you travel frequently. Most insurance companies will provide a referral service that can assist you in finding quality health care while away from your normal health care professionals.
Using Your Hospital Benefits
Most health insurance plans have specific guidelines for hospital care. Many require pre-authorization of treatment prior to being admitted for treatment. Unless it is a medical emergency, your health plan or primary care doctor will probably have to give advance approval for you to go to the hospital. Here are some important things you may wish to consider prior to needing the hospital benefits provided by your health plan.
Find out which hospitals in your area are part of your plans network. If you have an HMO plan you will need to coordinate hospital stays through your primary care physician and your care may be limited to one specific hospital. This is something that you should have already researched when researching a new health plan.
Find out if there are limits on how many days you can stay in the hospital and continue to receive benefits. Who is making the decision to discharge you at the end of your hospital stay? Does your insurance company leave this to the discretion of the attending physician?
If follow up care is needed after your hospital stay, will this be done at home or in a health care facility? Make sure that your health plan provides adequate coverage for the preferred method of follow up treatment. This is most important if you are diagnosed with a serious illness that requires full time care from a health care professional. If you prefer to be at home in this situation, make sure your health plan provides "in home" health care benefits.
You may also want to learn in advance how your health insurance company handles your requests for a second opinion. Do they pay for the office visit and test required for a second opinion? And, will they accept the finding of the second opinion if this physician is not authorized or part of their physician network.
Emergency or Urgent Care
If you have a true medical emergency, you should go to the nearest hospital as fast as possible. It is important for you to know what kind of medical problems are defined as emergencies and how to arrange for ambulance service, if needed. Typically, a medical emergency is defined as one that could be potentially life threatening. Most plans must be told within a certain time after emergency admission to a hospital. If the hospital is not part of the plan network, you may be transferred to a network hospital when your condition is stable. You may wish to know certain details about your health plan in the event that you need emergency medical treatment.
How does your health insurance carrier define an emergency medical situation? Get an example or a list of the health conditions that qualify for emergency medical benefits. If this medical condition is not an emergency, it may require more immediate treatment than your physician is able to provide. How does the policy define "urgent care" that must be obtained after normal business hours? Check with your plan to find out what it considers to be urgent care and also ask for a list of examples of acceptable medical conditions that are eligible for urgent care benefits. The answering service of your primary care doctor or the plan's hotline may be able to provide you with details on urgent care treatments and a list of participating facilities.
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