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QUESTIONS TO ASK
YOUR PLAN: PEOPLE WITH SPECIAL HEALTH NEEDS General Information about Managed Care Care Physician Treatment Centers INDEX |
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General Information • What services does the health plan cover? What services are excluded? Tip: Ask for a copy of the policy contract or Evidence of Coverage. These documents describe in detail any limitations in the services or benefits that a health plan will cover. • Describe the prior authorization process. What services require prior authorization? How long does this process usually take? • Does the managed care plan cover ______? (List the health care services that you or your family will need). Tip: Always be sure to check whether the services you need are covered, how often and the extent to which these services are covered. For example, you may want to ask if the health plan covers the services of medical subspecialists (i.e., pediatric cardiologists), mental health or substance abuse services, or alternative therapies (e.g., acupuncture or biofeedback therapy). Ask if the health plan has any limitations on these services (for example, number of visits or treatments, dollar limits, or copayment requirements). Do you need a referral from your primary care provider or advance approval by the health plan in order for these services to be covered? • Are pre-existing medical conditions covered? If not, what are the limitations? Tip: Under certain circumstances, health plans are allowed to limit coverage of people with pre-existing conditions. Pre-existing conditions are mental or physical conditions for which you sought medical advice, care or treatment within six months prior to your enrollment. Health plans, both HMOs and insurance companies, can limit coverage for up to 12 months (or 18 months in limited situations). A patient who has a pre-existing condition may be excluded from coverage for the services needed to treat that condition. The health plan must still cover other services that are unrelated to the pre-existing condition. Once you meet the 12- or 18-month pre-existing condition limitation period, you can not be subject to a pre-existing coverage limitation if you later develop health problems. In addition, you cannot be subject to a pre-existing coverage limitation if you change health plans and enroll in your new plan within 63 days of ending your prior health insurance coverage. Prescription Drugs • Are there limits on the types (brands, etc.) of drugs the primary care provider can prescribe (e.g. closed or restricted formulary)? Tip: Usually, there are several different drugs that can be used to treat a specific illness, such as asthma, depression, high blood pressure, high cholesterol, or ulcers. Often, health plans limit the medications they will cover for a particular illness. The list of covered drugs is called a formulary. Ask your health plan if your specific medication is covered on their formulary. If it is not, talk with your provider to see whether another medication that is covered will work just as well as the one that is not on the formulary. Beginning January 1, 2000, North Carolina law requires all health plans to have a process to cover drugs that are not on their formularies. Your physician will need to explain to your plan why the drug on the formulary is not adequate to treat your health care need. • Are there any limitations in the prescription drug coverage? Ask about copayment requirements, annual or lifetime limits, or limits on the number of pills you can receive at one time. Tip: Health plans may charge more for brand name drugs than for generic. Find out if the health plan will waive the additional copayment if your doctor prescribes the brand name drugs for medical reasons. Some plans limit the amount of money they will spend on prescription drugs (i.e., annual or lifetime limits), or limit the number of pills that you can fill at one time. You should ask these questions in advance if you have significant prescription drug needs. • Are there restrictions on where I can get my prescriptions filled? If so, ask for a list of participating pharmacies. Durable Medical Equipment, Orthotics and Prosthetics • Does the managed care plan cover durable medical equipment, orthotics or prosthetics? Tip: Always ask if the equipment you need is covered. How often will the health plan pay for new or replacement durable medical equipment? Are there any limitations on when the equipment can be replaced? Ask about price limits, rental vs. purchase, and if the network providers offer the equipment you need. Also find out if the health plan covers customized equipment, such as specialized wheelchairs or seating systems. If the plan will only cover standardized durable medical equipment, are you allowed to pay the difference between the standard option and a more customized product? Are wheelchair evaluations covered? • Is my coverage limited if I am able to use more than one type of durable medical equipment? For example, if I am able to use crutches or a cane some of the time, will my plan also cover a wheelchair that I need at other times? • To what extent are supplies and assistive technology devices covered? • How often does the managed care plan change its contracts with equipment vendors? Tip: This may be important for persons with disabilities who prefer a particular brand of durable medical equipment. Rehabilitative and Therapy Services • To what extent are rehabilitation services and therapies covered, such as occupational therapy, physical therapy, and speech therapy? Tip: Check the number of days and/or visits covered. You should also check to see if the health plan limits when services will be covered. For example, some health plans limit therapy services to conditions that are expected to show significant improvement in a short time. Health plans that limit therapy services in this manner are likely to exclude therapy services for preventive or habilitative purposes. • Does the health plan limit where you can obtain therapy ?services? Tip: Some health plans limits where you can obtain therapy services. If you need regular therapy services, you should ask for a listing of participating therapists. Find out what choice you have to pick from the therapists in the health plan’s network. Mental Health and Substance Abuse Services • To what extent are mental health and substance abuse services covered? Are there any day or dollar limits or other limitations? Tip: Check the number of days and/or visits covered. Some plans limit the number of days that the plan will cover for inpatient or outpatient mental health services. Many plans in North Carolina limit the amount of substance abuse services covered–typically, to $8,000 of services in a year or $16,000 over the course of the person’s lifetime. It is also important to find out if you need approval from the health plan or your primary care provider before seeking care from a mental health or substance abuse professional. Some plans also limit the types of services covered (for example, many plans exclude family therapy and psychiatric residential care). • Does the health plan exclude specific mental health conditions from coverage? Tip: Many health plans exclude coverage for specific mental health conditions. For example, some plans exclude coverage for mental retardation, learning disorders, behavioral disorders, autism or organic brain disorders. • Does the health plan limit where you can obtain mental health or substance abuse services? Tip: Some health plans limits where you can obtain mental health or substance abuse services. Ask for a listing of participating providers and find out what choice you have to pick from among these providers. Other Services • Will the health plan pay for me to accompany my child or spouse if he or she needs to travel to obtain needed care? • To what extent are experimental or investigational services covered? Tip: Most managed care plans exclude coverage of "investigational" or "experimental" treatment. This includes services, drugs, or procedures that are being tested to determine their effectiveness as part of a clinical trial. However, health plans offered to state employees are required to cover clinical trials in certain situations. Coordination of Services • Does the health plan coordinate its services with other community institutions and organizations? Tip: if you have a child with special health needs who is enrolled in the Individuals with Disability Education Act (IDEA) program, you may want to know if the health plan will work with the school system in providing care to your child. |