Health Insurance Articles
Looking For Gaps In Your Existing Health Insurance Coverage
2010-12-13
Even the best health insurance policy has gaps in coverage. The time to look for these gaps is before you need medical care. When an emergency or medical condition arises, the last thing that you need is the additional stress of finding out the limitations of your health insurance coverage. The good news is that there are actions you can take to identify gaps in your policy.
The first step to finding gaps in your health insurance coverage is to contact your insurance provider and request a full copy of your insurance policy and contract. Most of the time, insurance companies provide slick comparison charts and simple descriptions of the health insurance policy's coverage. While these materials can help give you a basic idea about the policy's coverage, they will not help you to identify important gaps in your policy coverage. For this reason it is important to request a full copy of the policy contract and read over it carefully.
Once you have a full copy of your health insurance contract, the first thing to carefully read over is the criteria the insurance provider uses to determine medical necessity. The insurer's definition of medical necessity is part of the contract that future coverage decisions will center around. No matter what medical procedures or hospital stays are covered in the policy, using their particular definition, the insurance company may deem treatment not medically necessary.
Once you have reviewed the definition of medical necessity used in health insurance policy, the next step to identifying gaps in coverage is to read through the policy looking for exceptions. Every health insurance policy has exceptions. For this reason, it is important to read through your policy carefully, including the footnotes and fine print, to identify often underplayed exceptions within your existing policy.
It is also important to review your health insurance policy's rules about prior authorization and specialty care. Many insurance policies require prior authorization for care. This is often true even in the midst of an emergency. It is important to understand the rules in place about prior authorization because if it is required and you do not get prior authorization, many insurance policies will not pay for the care episode at all, no matter how high the cost. Similarly, it is important to understand the policy requirements for specialty care. It is important to understand whether a referral is needed to see specialist and whether and under what circumstances you can see specialists out of network. Like rules about prior authorization, it is important to understand the policy's rules about specialist care so that you do owe substantial unexpected costs in the event that you need care.
