| Navigating the health insurance set of rules and instructions can be confusing and frustrating. There are many types of plans that cover – or do not cover – a wide diversity of health services. How can you be sure of what's covered by your health insurance plan.
• Covered services are outlined in the package of medical benefits listed in your insurance. These services can include screening, medicines and various treatment methods. Your policy also lists the forms of services that are not covered by your insurance company. As you have probably found out, you need to pay 100% for any uncovered medical care and treatment that you get. You may still have to pay for a part of a covered service or a part of the full cost.
• Medical necessity and medical benefit: A medical necessity is not the same as a medical benefit. A medical benefit is determined by your physician. A medical benefit is something that your insurance policy has agreed to cover. In some cases, you doctor might decide that you require medical treatment that is not covered by your insurer. This is because insurers base their policies on what is commonly good for the majority of people. Insurance companies cannot possibly be fully aware of all the combinations of treatments and services that will be good for each person.
So what can be done to stay away unpleasant surprises? Your medical practitioner will try to be familiar with your insurance policy so he or she can provide you with covered medical treatment. Nevertheless, there are so many different policies that it is impossible for him or her to be aware of specific details of each plan. By coming to grips on your policy, you can help you medical practitioner select medical care and treatment that is covered in your policy. Here are several recommendations:
• Read through your insurance policy. It is better to be fully aware of what your insurer will pay for before you receive a service, have examined or fill a prescription. Some forms of care might need to be approved by your insurance company before your medical practitioner can provide them. This is normally the case for more expensive testing, such as CT and MRI scans, operation or appointments with specialists.
• For some types of covered medical treatment, the number of treatment covered per year is limited. This frequently applies to mental health treatment and physical, occupational and speech therapy.
• Remember that your insurer, not your medical practitioner, make decisions about what will be paid for and what will not.
Most of the things your physician advises will be covered by your insurance plan, but some may not. When you have a testing or treatment that is not covered or you get a prescription filled for a medication that is not covered in your policy, your insurance company will not pay the bill. You can still get the medical care your physician recommended, but you will need to pay for it yourself. |
