Tips for Dealing with Insurance Companies

• Choose the right plan for you and your family based on what you need. 

  • If you or a family member has a significant medical issue or if you know that you will be using your insurance more than others, you may want to choose a plan with a higher premium that you pay monthly, a lower deductible and lower out of pocket maximum.  It might help to know what you will be paying monthly instead of having a higher deductible that requires you to pay out-of-pocket before insurance covers anything. 

  • If you and your family are fairly healthy and you know you likely won't use your health insurance very often, you may opt for a lower monthly premium, higher deductible and higher out-of-pocket maximum plan. 

  • Some high deductible plans offer a Flex Spending Account (FSA) or Health Savings Account (HSA).  This is like a savings account that is funded by pre-tax dollars from your paycheck.  Some employers will also contribute to it for you.   If you don't want to worry about not having cash to cover some medical expenses, you can have a set amount of money taken out of your paycheck before taxes are applied and added to the account.  

    • NOTE: HSA funds tend to "roll-over" if not used.  FSA funds typically DO NOT "roll-over" if not used.  

    • If you have extra funds than what you planned at the end of the year and they are going to expire, you can go to websites like FSAStore.com to purchase over the counter items that you can use.  This also includes medical devices like blood pressure monitors, stethoscopes, etc.  You can also purchase items in stores like Walmart, Target, retail pharmacies, etc.  Amazon also accepts payment from HSA and FSA cards. 

• Understand the basic structure of your plan. 

  • Check out the Insurance Terminology - Common Definitions page to learn about common terminology and definitions used by insurance companies.

  • Make sure the care you are planning to receive is a covered benefit PRIOR to receiving the care, if possible. 

  • Request to have copies of the following benefit documents sent to you:

    • Provider and Pharmacy Registry

    • Drug Formulary

    • Evidence of Coverage

    • Member Handbook

    • Any other "plan documents" that they can send you

  • You can also get digital copies of these documents online from your plan. 

  • Keep all of your policy documents handy and accessible so you can refer to them when needed

• Use in-network providers whenever possible. 

  • Using in-network providers who participate with your insurance network will make the cost of care cheaper.   This includes doctors, pharmacies, labs, outpatient clinics and hospitals.  Make sure these are all in-network with your insurance policy. 

  • Keep in mind that just because providers have been in-network in the past, doesn't mean they still are.  Make sure to check periodically, and also pay attention for announcements that may state that they will be going out of network in the future. 

•  See if your prescriptions are available as a generic drug.

  • Prescriptions are usually dispensed as either a brand name, generic name, or compounded.  

  • Generic drugs are usually much cheaper than the brand.

  • Compounded drugs may not be covered at all. 

  • If you need the brand name due to an allergy or effectiveness, you can request that your doctor writes a prescription for you and marks "Dispense as Written" on it.  The pharmacy should give you the brand medication, but keep in mind, you may have to pay more and in some cases, your insurance may not cover it at all.  If you are having issues with this, visit the "Steps to Take" page and scroll down to "Insurance Refusing to Cover a Brand Name Prescription?  Try This" section for advice on how to try to get it covered. 

• Compare your "Explanation of Benefits" with your medical bills before paying.

  • "You can request an itemized bill from your healthcare provider that breaks down what was charged for each service. Make sure you haven’t been charged for procedures or items you didn’t receive. Don’t pay a bill for care you thought was covered until you receive an explanation of benefits document from your insurer explaining why your claim was denied. An Explanation of Benefits, often called an EOB, is a document that shows the healthcare services you received, what your health insurance policy paid and what you owe. If what your EOB says you owe does not match your medical bill, call your provider to check and don’t pay the bill if they don’t match. You can also call your insurance company for more information."

• Understand your right to appeal.

  • You have a right to appeal any decision your insurance company makes that you disagree with.  

  • You, your doctor, or your representative can file an appeal.  

  • There are several levels of appeals if you disagree with a decision. 

  • Don't be afraid to appeal and advocate for yourself.  

Choosing a health insurance plan can be complicated. Knowing just a few things before you compare plans can make it simpler.

• The 4 “metal” categories: There are 4 categories of health insurance plans: Bronze, Silver, Gold, and Platinum. These categories show how you and your plan share costs. Plan categories have nothing to do with quality of care.

• Your total costs for health care: You pay a monthly bill to your insurance company (a "premium"), even if you don’t use medical services that month. You pay out-of-pocket costs, including a deductible, when you get care. It’s important to think about both kinds of costs when shopping for a plan.

• Plan and network types — HMO, PPO, POS, and EPO: Some plan types allow you to use almost any doctor or health care facility. Others limit your choices or charge you more if you use providers outside their network.