Health Insurance Rules
[The following health insurance rules apply when the physicians and facilities are managed by the HMO or insurance operation. The insurer does not determine these health insurance rules for doctors and facilities it does not manage. Networks may have some health insurance rules, but they will not determine such things as when offices are open or how to make appointments - ed.]
Learning what you can expect from your health plan and how it works are key steps to getting the care you need. Ask these questions:
- When are the offices open? What if I need care after hours?
- How do I make appointments? How quickly can I expect to be seen for illness or for routine care?
- If I need lab tests, are they done in the doctor's office or will I be sent to a laboratory?
- Will most of my appointments be with the primary care doctor? Will nurse practitioners or physician's assistants sometimes give care as well?
- Is there an advice hotline? Some plans have toll-free phone services that help members decide how to handle a problem that may not require a doctor's visit.
Find out how your plan provides care outside the service area and what you must do to get care. This is especially important if you travel often, are away from home for long periods, or have family members away at school.
9. What if I Have to Go to the Hospital?
[Insurers operate according to rules and so your coverage may have health insurance rules to be aware of to get the best benefit from the coverage. - ed.]
The time to find out what rules your plan has on hospital care is before you need it.
Planned Hospitalizations
Unless it is a medical emergency, your health plan or primary care doctor will probably have to give advance approval (preadmission certification) for you to go to the hospital. Otherwise, the cost of your hospital care may not be covered. Ask these questions:
- What hospitals are part of the plan network?
- Is there a limit on how long I can stay in the hospital?
- Who decides when I am to be discharged?
- Will needed followup care, such as nursing home or home health care, be covered by the plan?
- If I have a serious medical problem, will the plan provide someone to oversee care and make sure my needs are met?
Ask how your plan handles getting a second doctor's opinion on whether surgery or another treatment is needed. Are second opinions encouraged or required? Who pays?
[Precertification and network membership are important health insurance rules to understand and monitor. - ed.]
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. 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. Ask these questions:
- How does the plan define "emergency care?" What conditions or injuries are considered emergencies?
- How does the plan handle "urgent care" after normal business hours? Urgent care is for problems that are not true emergencies but still need quick medical attention. Check with your plan to find out what it considers to be urgent care. Examples may include sore throats with fever, ear infections, and serious sprains. Call your primary care doctor or the plan's hotline for advice about what to do. The plan may also have urgent care centers for members.
- How do I get urgent care or hospital care if I am out of the area? How must I tell the plan and how soon after I get the care?
[All plans should waive their regular health insurance rules for emergencies. Be sure yours does, but you need to know how an emergency is defined and ask the facility to be sure to code the claim as an emergency. Include the definition with your plan summary of its health insurance rules. - ed.]
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