A Consumer Guide to Handling Disputes with Your Private or Employer Health Plan
|  |
| < Return to Report Index | | CHECKLIST FOR DIAGNOSING YOUR COVERAGE
Knowing your coverage will help avoid misunderstandings. Review your plan documents and complete the following worksheet to (1) make sure you understand your coverage, and (2) have the necessary information ready in a convenient place when you need to arrange care. What follows is a checklist to help you remember information about your coverage:MY HEALTH PLAN COVERAGE My health plan coverage is through: | [ ] | My employer -- check if:
[] my plan is an insured plan; any plan denials are eligible for state external review
[] my plan is a self-funded plan; any plan denials are NOT eligible for state external review | | [ ] | A policy I bought myself | | [ ] | An association-sponsored policy (such as through a trade, civic or educational organization) | | [ ] | Other: _______________________________ |
My health plan is a:
| [ ] | Health maintenance organization (HMO) | | [ ] | Preferred provider organization (PPO) | | [ ] | Point-of-service plan (POS) | | [ ] | Traditional indemnity (also known as fee-for-service)
|
Plan number to call if I have a problem: _____________________________
My primary-care physician is: ________________________________________
Physician’s phone number: ___________________________________________
I need a referral from my primary-care physician for:
| [ ] | Lab and x-ray tests | | [ ] | Gynecologist (for well-woman exam) | | [ ] | Gynecologist (for other concerns) | | [ ] | Pediatrician | | [ ] | Other specialist visits | | [ ] | Surgery | | [ ] | Other: __________________________________________ |
My primary-care physician has the following requirements for obtaining referrals:
| [ ] | Requires an office visit
| | [ ] | Requires _____ days advance notice | | [ ] | Other: ___________________________________________ |
My primary-care physician can refer me to specialists who:
| [ ] | Are part of his or her group practice | | [ ] | Are on the health plan network list | | [ ] | Are outside of the health plan network only if there are no similar specialists within the network | | [ ] | Are outside of the health plan network | | [ ] | I do not need a referral from my primary-care physician |
I have reviewed the Exclusions and Limitations section in my Evidence of Coverage. My health plan will not pay for, or limits, the following services:
| [ ] | _________________________________________________
| | [ ] | _________________________________________________ | | [ ] | _________________________________________________ | | [ ] | _________________________________________________ | | [ ] | _________________________________________________ |
My plan will cover services at the following hospitals:
__________________________________________________________
__________________________________________________________
__________________________________________________________
What should I do if I need care while I am out of my plan’s service area?
For non-urgent care: | ________________________________ | phone: | ______________________ | In an urgent situation: | ________________________________ | phone: | ______________________ | In an emergency: | ________________________________ | phone: | ______________________ |
If you have a PPO or POS plan:
Although I can use out-of-network doctors for most services, I cannot use out-of-network doctors for the following services:
| [ ] | Mental health
| | [ ] | Substance abuse | | [ ] | Other: ___________________________________________ |
If I use out-of-network providers, I will pay:
| [ ] | $_______ annual deductible
| | [ ] | _____% coinsurance for charges exceeding the deductible. |
| | < Return to Report Index | |
|
