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.

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?

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.

Tip: Usually, there are several different drugs that could be used to treat a specific illness, such as asthma, depression, high blood pressure, high cholesterol, or ulcers. However, often, health plans will only cover a particular drug for an illness. 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 will require 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.

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 heavy prescription drug needs.

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.

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.

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)?

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.

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.

Tip: Find out if your health plan will pay for you to accompany your child or spouse if they have to go out of the service area for treatment.

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.