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Bureau of Insurance

Understand Your Coverage

10 Tips to Help You Understand Coverage Under Your Managed Care Health Insurance Plan

  1. It is well worth your time and effort to read thoroughly and understand as much as you can from documents provided to you by your Plan. This includes your Evidence of Coverage, as well as other documents such as Member Handbooks, Provider Directories, Newsletters, and any other material provided by your plan.
  2. Know as much as you can about how your plan works before you need to use it. It is most important to know beforehand about such things as selecting a primary care provider, obtaining referrals to specialists, copayment requirements, and access to emergency care. Realize that your plan will probably not cover all of your medical expenses, and that you may have to pay part of the cost.
  3. Ask questions about anything that is not clear, confusing, or that you do not understand.
  4. If you need assistance, talk with your plan's representatives, your agent, your employer, or contact the Office of the Managed Care Ombudsman.
  5. If a problem arises, you should first contact your Managed Care Health Insurance Plan. Your evidence of coverage contains a telephone number and mailing address for your use in contacting the plan. Be sure to record the day you call, the name of the person you speak with, the title of the person you speak with, and a summary of the conversation.
  6. If you or your physician have difficulty obtaining approval for medical care, or if you experience difficulty with a claim, know what your rights are according to your particular plan.
  7. Understand your right to appeal decisions made by the plan that are not in your favor (an "adverse decision"), and follow the instructions provided by your plan to appeal an adverse decision. You need to familiarize yourself with the various levels of appeals and grievance procedures that are available to you directly through your plan.
  8. If you write a letter to your plan to file an appeal or a grievance, document the facts that support your case. Keep your letter business-like and clearly state why you believe you are correct. Include any supporting documents from you or your physician that support your appeal or grievance.
  9. Follow the time lines established by your plan for filing any appeals, grievances or complaints. Record the date you provide information to your plan, and be sure to keep a copy of any letters you send to your plan.
  10. At any point in the process, you can contact the Office of the Managed Care Ombudsman for assistance.