Minnesota Attorney General's Office
1400 Bremer Tower
445 Minnesota Street
St. Paul, MN 55101
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II . Understanding Your Policy
It seems that insurance policies get longer and longer each year. It's not uncommon today to find policies over 50 pages long. Faced with a reading assignment this big and complex it's tempting to just give up. But don't. Your policy is important. So-- dive in! Your health is worth the effort.
Most insurance policies are put together in a similar way. Most have a "Coverages" section, an "Exclusions" section, a "Definitions" section and a "Conditions" section. By using these three steps, you can turn reading this lengthy document into a fairly manageable task:
STEP ONE-- IS THERE COVERAGE?
Start by reading the Coverages section. Does the treatment you need appear to be covered? If you encounter important terms, check the Definitions section for more information.
STEP TWO-- IS THERE AN EXCLUSION?
Next, read the Exclusions section. If you believe you have found coverage, is there an exclusion that takes coverage away? Again, refer to the Definitions section if you need terms defined.
STEP THREE-- WHAT CONDITIONS APPLY?
If you determine that there is coverage and that no exclusion takes away coverage, review the rest of the policy to determine whether any conditions apply. Conditions may include requirements that you:
a. obtain preauthorization from the health plan for a particular treatment.
b. pay a deductible or copayment.
C. use a particular health care provider.
If you are covered under an individual or group "fully-insured" policy, the health carrier must provide a copy of the policy to you. If you have coverage through an employer's self-insured health care plan, the employer must provide you with a copy of both the summary plan description and the master plan.
PREMIUMS, CO-PAYS, DEDUCTIBLES, AND ANNUAL MAXIMS
Under most policies you will be responsible for certain payments. In recent years, because of the increased cost of health care, some employers and health plans have typically required consumers to pay more in out-of-pocket costs. Look at your policy to determine the payments you must make. Here are some of the main payments to look at:
- Premium: This is the amount you pay to obtain insurance coverage. Compare premiums among carriers and among plans of the same carrier.
- Deductible: A health care deductible works the same way it does for other types of insurance.For instance, you may be responsible to pay for the first $500 of treatment before your policy kicks in.
- Co-Pay: This is the amount you pay each time you receive treatment or a prescription drug. For instance, your health plan may require you to pay $10 each time you go to the doctor.
- Co-insurance:This is a percentage of the cost that is charged for certain services after the deductible has been paid. For example, a co-insurance level of 20% means that the plan pays 80% of the costs, and you pay the remaining 20% of the cost.
- Annual out-of-pocket maximum:This is the maximum amount you will be required to pay each year in co-pays and deductibles.
FREQUENTLY ASKED QUESTIONS
To help you understand your rights as a patient in managed care, we've provided answers to some of the most commonly asked questions.
MY INSURER WANTS TO CUT MY HOSPITAL STAY SHORT. WHAT CAN I DO?
Enlist your physician as your advocate. Talk frankly with your doctor. Express your concerns and ask the doctor to intervene with the health plan. Ask the doctor to explain to the health plan the negative health consequences you could suffer if you leave the hospital. You should also express your concerns directly to your health plan, preferably in writing.
MY PRIMARY CARE PHYSICIAN WILL NOT GIVE ME THE REFERRAL THAT I NEED TO SEE A SPECIALIST. I AM VERY CONCERNED ABOUT THIS. WHAT CAN I DO TO GET A REFERRAL?
Some health plans use primary care physicians as "gatekeepers" to control the treatment and referrals you receive. In addition, some health plans pay the gatekeeper a "capitated" payment. This means that the gatekeeper receives a flat fee regardless of the amount of treatment you need. The more referrals the patient needs, the less money the gatekeeper makes.
Tell your physician about your concerns and why you believe it is necessary for you to receive a referral to a specialist. Consider putting your concerns in writing. If this doesn't work, you may also wish to consider changing primary care physicians.
Finally, if you still can't get a referral to a specialist, consider locating a specialist on your own and referring yourself. While you may have to pay for the treatment, it may keep your health from being jeopardized.
I WANT TO SEE A PHYSICIAN OUTSIDE OF MY HEALTH PLAN'S NETWORK. WHAT CAN I DO?
Some health plans allow you to see a physician outside of your network if your primary care physician authorizes it. Explain to your primary care physician why you believe it is necessary to see a physician outside the network. Ask your primary care physician for a referral. If the primary care physician refuses, ask why.
Some health plans allow you to go outside the network without a referral but require you to pay a greater share of the cost if you do.Other plans require pre-authorization even with a referral. Read your health plan to find out whether you may go outside the network and get reimbursed later.
Finally, be prepared to convince the health plan why you believe that there is no doctor in the network who can adequately treat your medical condition. For instance, maybe you have a particularly rare or unusual disease which requires specialty care not available in the network. If so, explain this to the health plan.
MY MEDICAL CONDITION REQUIRES ME TO MAKE REPEATED VISITS TO SPECIALISTS. DO I NEED A REFERRAL EACH TIME?
Under Minnesota law health plans must have procedures you can use to apply for a standing referral to a specialist. Check the criteria you must meet in order to obtain a standing referral. Contact your health plan for more information, then enlist your physician's help to request a standing referral. Minnesota law also allows women direct access to obstetricians and gynecologists for maternity care and annual preventive health examinations, so the health plan cannot require a referral for these services if they are provided within the enrollee’s network.
UNDER WHAT CIRCUMSTANCES MAY A HEALTH PLAN IMPOSE A PRE-EXISTING CONDITION LIMITATION?
It’s common to run into a pre-existing condition limitation when you apply for health coverage from a new health carrier. A pre-existing condition is a medical condition (other than pregnancy) for which you seek medical advice or treatment within six months of the time you apply for health coverage. This means you will not be covered right away for pre-existing conditions.
A health carrier may apply a pre-existing condition limitation for up to 12 months from the date you first become covered. For example, if you received treatment for a heart condition within six months of being covered by a new carrier, the new carrier may deny any claims for care you need due to that heart condition for 12 months after your coverage starts.
If you are a “late entrant,” a health carrier may apply a pre-existing condition limitation for up to 18 months. A late entrant is an individual who did not apply for coverage in a timely manner. For example, if you become eligible for coverage after working at a new job for 30 days, you must then apply for coverage or be considered a late entrant.
However, the period of time a health carrier can limit coverage for the pre-existing condition is reduced by the length of time you have had continuous qualifying coverage. Under the example above, if you had continuous qualifying coverage for nine months before applying for coverage through the new carrier, the new health carrier has to give you nine months credit against the 12 month preexisting limitation period for the nine months that you had qualifying coverage, so the new carrier could only deny claims for your heart condition for three months after enrollment. Continuous coverage means maintaining uninterrupted coverage. A person is considered to have continuous coverage if he or she applies for coverage within 63 days of terminating a qualifying coverage. If you did not maintain uninterrupted coverage or did not apply for coverage until more than 63 days after your previous coverage terminated, then the new carrier could impose the pre-existing condition limitation for the entire 12 month period (or for 18 months if you were a late entrant).
MY EMPLOYER JUST CHANGED HEALTH PLANS AND MY DOCTOR IS NOT INCLUDED IN THE NEW HEALTH PLAN. DO I NEED TO STOP SEEING MY OLD DOCTOR RIGHT AWAY?
State law says health plans must have written procedures which allow you to see your old doctor for certain conditions. For example, if you have special needs, such as an acute condition or a life-threatening illness, or special circumstances, such as a second or third term pregnancy, or a major disability that lasts for at least a year, you may continue seeing your doctor for up to four months after becoming covered by a new health plan. If your doctor certifies that you are expected to live less than six months, the new health plan must allow you to see your regular doctor for the rest of your life. This is called “continuity of care.” Upon request the health plan must give you a copy of the written procedures for continuity of care.
IN MY HEALTH PLAN SAYS THAT IT WON'T PAY FOR EMERGENCY SERVICES I RECEIVED BECAUSE I COULD HAVE WAITED UNTIL THE NEXT DAY FOR A CLINIC APPOINTMENT INSTEAD OF GOING TO THE EMERGENCY ROOM. WHAT ARE MY RIGHTS?
Minnesota law requires that emergency services be covered whether they were provided by a participating provider or not. These services are also covered if you are within or outside your health plan's service area. When considering coverage for emergency services, the health plan must look at the following:
- a reasonable person's belief that the circumstances required immediate medical care that could not wait until the next working day or next available clinic appointment;
- the time of day and day of week the care was provided;
- the symptoms at the time the patient received the emergency care and not just the after-the-fact diagnosis;
- the patient's efforts to follow the health plan's procedures for obtaining emergency care, together with any circumstances that precluded using these procedures; and
- any circumstances that precluded the patient from using the health plan company’s established procedures for obtaining emergency care.
MY HEALTH PLAN WILL NOT APPROVE A SERVICE THAT MY DOCTOR SAYS I NEED. WHAT CAN I DO?
Health plan companies that require authorization for services must have written procedures for reviewing your request. These utilization review procedures allow a health plan to evaluate the necessity and appropriateness of a procedure. Either you or your health care provider can request approval for a service. If the health plan does not approve the service, it must tell you how you can appeal that decision. If the utilization review organization denies coverage for a procedure, your health provider can request an expedited review. The utilization review organization must give a decision with 72 hours of receiving an expedited appeal.
Next Page- III: Tips on Fighting Back