ASSURING COVERAGE FOR HEALTH CARE SERVICES

Does My Health Plan Have to Cover All the Health Care I Need?

Your health plan does not have to cover all the health care services that you need. No insurance company covers all health care services. The HMO or insurance company is only required to pay for services that are mandated by state law or covered under your health plan contract (described in your Evidence of Coverage). For example, some plans specifically exclude coverage of mental health services or prescription drugs. Health plans are not required to cover these services unless you purchased a rider to cover these services. Similarly, some health plans put limits on the extent of coverage, or the situations when the services will be covered. Some health plans, for example, pay for a limited number of physical, occupational or speech therapy visits. The health plan is not obligated to cover additional services, no matter how much you may need them. However, your physician has an ethical responsibility to discuss all appropriate treatment options regardless of whether the service is covered under the plan.

Note: Health plans are not required to pay for covered services if you fail to obtain a required referral or prior authorization or if the HMO determines that the services were not medically necessary. Therefore, it is very important to always make sure you understand your plan’s requirements and follow them.

Do I Need to Get a Referral from My Primary Care Provider (PCP)?

HMOs usually require members to get referrals from their PCP before the health plan will pay for specialty care, high-technology services or non-emergency hospital admissions. Your Evidence of Coverage will specify when you need a referral. As a general rule, your PCP must refer you for most health care services provided outside his or her office. The two notable exceptions are for emergency care and for care related to the female reproductive system from participating OB-GYNs. In addition, referrals to specialists are not usually required if the person is enrolled in an open-access HMO, point-of-service plan (POS) or a Preferred Provider Organization.

Note: It is important to understand exactly what services your referral covers.

People sometimes have problems with their HMO because the referral did not cover all the services that they received. For example, a member may obtain a referral to a specialist and assume that all the diagnostic tests the specialist orders automatically will be covered. However, some health plans may require an additional referral from the PCP or prior authorization from the health plan before covering certain procedures (see below). Other problems can arise when a person is referred to a specialist for on-going care. Some PCPs or HMOs limit the number of visits or length of time a referral will cover. Therefore, it is important to understand what the referral covers and to contact your PCP if an additional referral is needed.

When Do I Need Prior-Authorization?

In addition to the PCP referral requirements, most HMOs require that certain services be approved in advance by the plan. This is called prior authorization or precertification and is necessary before the HMO will pay for the service.

Each HMO has its own rules for which services or procedures require prior authorization. As a general rule, most HMOs require non-emergency hospitalizations, surgery or therapy services be approved in advance. Similarly, many HMOs require prior authorization for certain high-technology (and high-cost) services such as MRIs (Magnetic Resonance Imagings, which are special images or pictures of the inside of the human body). The HMO should specify which services require prior authorization in your Evidence of Coverage. Your membership card should include a toll-free number to call when you need to get prior approval from the HMO.

Some HMOs place the responsibility of obtaining prior approval on your physician or health care provider. In these instances, the HMO will deny payment to providers who fail to obtain the necessary approval. Some HMOs prohibit providers from charging members if it was the provider who failed to get authorization. Other HMOs place the responsibility on the members and allow the physician to charge for services if the member fails to get prior approval.

Note: It is important to always obtain prior authorization when required. Otherwise, the HMO does not have to pay for the services you received even if they are listed in your Evidence of Coverage. If you are not sure if you need to get prior authorization, call your HMO.

My Plan Said It Would Not Cover My Services Because They Are Not Medically Necessary. What is Medically Necessary?

Health plans often limit covered services to those that are medically necessary. If an HMO tries to limit coverage to medically necessary services, it must use the definition that is specified under North Carolina state law. North Carolina defines medical necessity as the services or supplies that are:

• Provided for the diagnosis, treatment, cure or relief of a health condition, illness, injury or disease and not for experimental, investigational or cosmetic purposes;
  
• Necessary for and appropriate to the diagnosis, treatment, cure or relief of a health condition, illness, injury, disease or its symptoms;
  
• Within generally accepted standards of medical care in the community;
  
• Not solely for the convenience of the insured, the insured’s family or the provider.
  

In other words, the health plan will examine whether the treatment or service that you or your physician wants is appropriate to treat your health condition. Experimental treatments are usually not covered. A health plan is allowed to examine the cost-effectiveness of alternative services or supplies when determining which services or supplies will be covered.

Will My Health Plan Pay If I Need To Go to the Emergency Room?

HMOs and other insurance companies must pay for your costs of emergency room services if you reasonably thought that you had a medical emergency when you sought care. You do not need to seek prior authorization to obtain emergency care. The HMO or insurance company will be required to pay for the screening and any services needed to stabilize your condition. If possible, you should seek care from a hospital that is in the HMO’s network. This will make it easier for follow-up care once you are stabilized. However, the HMO will still be required to pay for your care if you seek care from a non-network hospital if you thought the delay in going to one of the HMO’s network hospitals would worsen your health condition. The HMO or insurance company may charge its regular coinsurance, co-payments or deductibles but may not charge you an additional cost for using a non-network provider.

The North Carolina law does not mean that all visits to the emergency room are covered. You cannot, for example, seek care in the emergency room for a common cold or sore throat, or just because your physician’s office was closed. HMOs do not have to pay for non-emergency care that most reasonable people would not think was an emergency. If you are not sure whether you need to seek care in an emergency room and you think the delay will not cause you (or the patient) harm, you should call your PCP or the HMO for prior authorization. If you receive prior authorization, the HMO must cover the care you receive.

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