My Benefits Primer

You're Enrolled, Now What?

Making the Most of Your Health Benefits

You've selected a plan that's right for you, now make the most of your options. Gaining popularity, consumer-directed or consumer choice health plans are a relatively new type of health planhealth plan
A health plan that you buy or that is provided by your employer. It pays for health care services. I... more
designed to give consumers more control over their health benefitbenefit
The term "benefit" may refer in general to a health plan (your "benefits"), specifically define the ... more
dollars. Navigating Your Health Benefits helps you fully maximize benefits by making smart choices and knowing the ins and outs of the plan's offerings.

At the Doctor

What is covered?

There is a long list of medical services that may or may not be covered by your plan. Some plans are limited to particular types of services such as hospitalization or dental care; others provide comprehensive benefits subject to certain exclusions and limitations. The terms of a health benefits planhealth benefits plan
A plan purchased by an individual or provided through an employer that provides payment for health c... more
are described in a plan document, which you should review carefully when choosing and using your health benefits planhealth benefits plan
A plan purchased by an individual or provided through an employer that provides payment for health c... more
.

Selecting a doctor

Your primary care physician, or PCP, is a doctor who is typically part of your health planhealth plan
A health plan that you buy or that is provided by your employer. It pays for health care services. I... more
net-work, and provides basic medical care for you and your family. If your plan requires referrals, this is also the doctor who will give you referrals to specialists, such as allergists or dermatologists.

Check your health benefits providerprovider
A licensed health care facility, program, agency, physician or other health professional that delive... more
's website for a list of physicians in your area that participate in your networknetwork
Also called "provider network." A panel of physicians, hospitals and other health care professionals... more
. If you have your eye on a PCP that is not in your health planhealth plan
A health plan that you buy or that is provided by your employer. It pays for health care services. I... more
's networknetwork
Also called "provider network." A panel of physicians, hospitals and other health care professionals... more
, be sure to ask about extra out-of-pocketout-of-pocket
Amounts such as copayments and deductibles that an individual is required to contribute toward the c... more
expenses you may have to pay to see this physician.

If you've narrowed down your list to several physicians, you may want to meet with a few to determine which doctor is the best fit for you. Here are some questions to get you started:

  • What are the office hours?
  • Does the doctor have a subspecialty that fits your needs, such as experience working with children, the elderly, or people with disabilities?
  • Is the doctor available over the phone during office hours? If not, is there a nurse who can answer your questions?
  • Does the doctor use e-mail?
  • What hospital(s) does the doctor use?

You should also be comfortable with the doctor's typical practices:

  • Does he/she use a physician assistant?
  • How long does it take and how easy is it to book an appointment?
  • What's the average wait time once you've arrived at the office?
  • Does he/she generally call or set-up a follow up appointment to inquire about my pro-gress/well-being?

Seeing specialists

Specialists are experts who practice one specific area of medicine. To find a specialistspecialist
A physician who provides medical care in a medical or surgical specialty or subspecialty (for exampl... more
:

  • Check your health planhealth plan
    A health plan that you buy or that is provided by your employer. It pays for health care services. I... more
    's website for quality rankings on specialists.
  • Visit the website of an organization or academy associated with your specialty needs.
  • Check your local or regional monthly magazine for a directory or ranking of specialists in your area.
  • Ask your primary care physician, family and friends for recommendations.
  • If you're having trouble getting an appointment with a specialistspecialist
    A physician who provides medical care in a medical or surgical specialty or subspecialty (for exampl... more
    , call your PCP - they might be able to help.

Find out if your plan allows you to see a specialistspecialist
A physician who provides medical care in a medical or surgical specialty or subspecialty (for exampl... more
without a referralreferral
In some health plans, you must receive a referral from your primary care doctor to see a specialist ... more
. Some plans require that your PCP refer you to specialists like allergists and dermatologists.

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Preauthorization

Under some health plans, you're required to receive advance authorizationauthorization
A health plan's process for approving payment for medical services covered by an individual's benefi... more
for particular medical services, called preauthorization or precertification. Check your plan documentsplan documents
Plan documents describe the details of a health plan - what services are covered, what services are ... more
to see if there are any services that require preauthorization and, if so, who is responsible for requesting it.

Getting lab work/tests

Before going for any tests or lab work, such as X-rays and diagnostic services, find out what's covered by your plan. Going to multiple locations to get tests and then find out results can be frustrating and time consuming. Work with your doctor to try to schedule many tests at once, or call ahead to try to schedule lab work during one of your regularly scheduled check-up appointments.

EmergencyEmergency
A serious medical condition resulting from injury or illness that arises su... more
services

While you can never plan for the unexpected, emergencies happen. It's important to check your plan documentsplan documents
Plan documents describe the details of a health plan - what services are covered, what services are ... more
to find out what emergencyemergency
A serious medical condition resulting from injury or illness that arises su... more
services are covered. You should also find out if your plan offers an emergencyemergency
A serious medical condition resulting from injury or illness that arises su... more
, 24-hour hotline or nurse helpline. If you are unsure whether you need to visit the emergencyemergency
A serious medical condition resulting from injury or illness that arises su... more
room, try calling the hotline first.

Not seeing your doctor

Given that many doctor's appointments take weeks or even months to get, how can you in-crease the likelihood of squeezing in an emergencyemergency
A serious medical condition resulting from injury or illness that arises su... more
appointment? Insiders say to befriend nurses and office administrators. Get to know them and make an effort to learn something about their family or professional accomplishments. Not only will they make your doctor appointments more pleasant, but it may help you get a last-minute appointment. Also, when you make your appointment, ask if you will see the doctor or a nurse practitioner.

In the waiting room

Long waiting periods in the aptly-named waiting room, and then again in the exam room, are top patient complaints. One way to cut down on wait time is to book the first appointment of the day, before the physician has a chance to fall behind schedule.

Medical history forms can be lengthy, especially for new patients. Call ahead to find out if your doctor's office can fax, mail or e-mail new patient documents, including your medical history and insurance information, to save yourself time in the waiting room.

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At the Drugstore

Filling prescriptions

For most people, prescription cost and convenience to fill are at the top of the list when com-paring benefits plans. It's important to know which prescriptions are covered by your plan, and how much you should expect to pay. Most health benefits plans that offer prescription drug coverage use a formularyformulary
A list of covered prescription drugs established by a health plan with the assistance of their Pharm... more
and provide different levels of coverage based on the drug's cost, ef-ficacy or other considerations (brand-name vs. generic, etc). Formularies are subject to periodic review and changes by a health planhealth plan
A health plan that you buy or that is provided by your employer. It pays for health care services. I... more
.

Some plans offer discount programs with prescription drug cards and mail order services. Check to see if your plan's prescription service allows you to call and speak to a pharmacist. At the very least, your plan's mail order prescription service should be able to connect you with a customer service department should you have any problems or need to request a different medication.

Doctor recommended prescriptions

What should you do if a doctor recommends a medication that isn't covered by your insurance or costs more than you can spend? Talk to your physician about generic alternatives or over-the-counter options, both of which frequently lower your out-of-pocketout-of-pocket
Amounts such as copayments and deductibles that an individual is required to contribute toward the c... more
costs.

Over-the-counter products

Keep in mind that over-the-counter products or medications that may be purchased without a prescription from your doctor, are also covered by your Flexible Spending Account dollars.

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At the Dentist

Check on dental, vision benefits

Some health plans offer discounts on products and services such as dental and vision care. You may also be offered a separate benefits plan for dental or vision care.

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At the Health Club and Other Savings Opportunities

Using consumer-directed plans

Consumer-directed health plans are relatively new, designed to give consumers more control over a portion of their health benefitbenefit
The term "benefit" may refer in general to a health plan (your "benefits"), specifically define the ... more
dollars, typically through a health fundhealth fund
A term applied to both Health Reimbursement Arrangements (HRAs) and Health Savings Accounts (HSAs) t... more
or account that can be used to pay for covered medical expenses. Some health funds, like a Health Savings Ac-count, allow unused dollars to be rolled over from year to year, are portable (meaning you can take it with you if you change jobs), and can be used for health care expenses in retirement.

Special services

Some plans offer discounts on products and services such as acupuncture, health club member-ships and nutritional supplements. Talk to your plan about this opportunity to save money on items and services you may already be using.

Doctors may or may not call you to check in on progress. Check your plan documentsplan documents
Plan documents describe the details of a health plan - what services are covered, what services are ... more
or ask your human resources department to see if your plan routinely covers follow-up appointments, likely to be scheduled within a few months from initial treatment.

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