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 plan designed to give consumers more control over their health benefit 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 plan are described in a plan document, which you should review carefully when choosing and using your health benefits plan.
Selecting a doctor
Your primary care physician, or PCP, is a doctor who is typically part
of your health plan network, 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 provider's website for a list of physicians
in your area that participate in your network. If you have your eye on a
PCP that is not in your health plan's network, be sure to ask about
extra out-of-pocket
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?
- 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 progress/well-being?
Seeing specialists
Specialists are experts who practice one specific area of medicine. To find a specialist:
- Check your health plan'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 specialist, call your PCP - they might be able to help.
Preauthorization
Under some health plans, you're required to receive advance authorization for particular medical services, called preauthorization or precertification. Check your plan documents 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.
Emergency services
While you can never plan for the unexpected, emergencies happen. It's
important to check your plan documents
to find out what emergency services are covered.
You should also find out if your plan offers an emergency, 24-hour
hotline or nurse helpline. If you are unsure whether you need to visit
the emergency 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 increase the likelihood of squeezing in an emergency 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.
AT THE DRUGSTORE
Filling prescriptions
For most people, prescription cost and convenience to fill are at the
top of the list when comparing 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 formulary and
provide different levels of coverage based on the drug's cost, efficacy
or other considerations (brand-name vs. generic, etc). Formularies are
subject to periodic review and changes by a health plan.
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-pocket 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.
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.
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 benefit dollars, typically through a health fund or account that can be used to pay for covered medical expenses. Some health funds, like a Health Savings Account, 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 memberships 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 documents 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.