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You cannot be a patient and a watchdog at the same time. When you are sick, you cannot be expected to negotiate the best care and coverage under your health insurance plan. Being ill is often a humiliating experience. Being denied  the care you feel you deserve adds to distress.
Pre-planning can save you and your family a lot of heartache. If you are contemplating
extensive medical care or are facing a serious illness, you may wish to arrange
for a trusted friend or family member to act on your behalf during the time
you will be incapacitated. You need to determine ahead of time the extent of
your health insurance benefits so that you know what care will and will not
be covered. You will need to know how your health care will be affected and
who will make the decisions regarding your treatment. Ask your health plan
the following questions:
- Will the procedure or surgery be covered? If so, what will the benefits be?
- Will the deductible be applied to the procedure or will I have “first dollar” benefits?
- Will there be any limits regarding the procedure or surgery?
- Is there preauthorization required? If so, do I have the responsibility or does it belong to my doctor?
- Will the benefits be reduced if I need to consult a specialist in an emergency situation?
- Your recovery should be your most important concern. You need peace of mind in order to direct your energy toward your health, rather than your health insurance coverage.
Effects of the Affordable Care Act:
The ACA made access to health insurance easier but it mandated certain benefits that may not have been covered in the past. The cost of these mandated benefits are shared by all insureds so that your premiums may have increased or your deductibles and copayments may have gone up. The ACA also limited the type of insurance plans available, so that so-called “Cadillac” health insurance plans have been virtually eliminated in the private marketplace and replaced with higher deductibles and copays.
During the “roll-out” of the ACA, many health plans had administrative problems in meeting the deadlines for enrollment so that some people were erroneously not listed as enrollees or had coverage cancelled for non-payment. Small employer groups lost coverage because their plans did not meet required mandates and the replacement group coverage was unaffordable so that employees were forced into the private insurance marketplace. Some people were given incentives to change coverage in order to receive subsidized premiums. In short, most people not covered through a large employer had to start over with new and unfamiliar benefits.
Know Your Benefits:
If you are not facing a medical emergency, you should take the time to thoroughly familiarize yourself with your health coverage. Know which procedures or medical services have a deductible and which do not. Before obtaining elective medical services verify that the provider(s) are actually contracted to the health plan, not just listed on the internet. Because of the administrative problems under the ACA, many health insurance carriers do not have accurate provider lists published on the internet for the particular health plans. Some of the subsidized health plans under Covered California, for example, have fewer medical providers and the listed providers on their website may not be contracted to your particular plan. If you do not obtain services from the contracted providers you may not be covered for services, or additional deductibles may apply. When in doubt, obtain a written statement from both the provider and the health plan that they are contracted with one another.
If you have concerns about your coverage or if you believe your health plan is denying you coverage that you are entitled to receive, the law office of Constance N. Zarkowski can help make a trying experience more tolerable by assisting you and your family in negotiating for the health care you are entitled to receive under your health plan.
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