What does your plan cover?
Your insurance policy should explain:
- Your health care benefits and any limits on the number of times you can use a specific benefit (for example, some plans only cover 10 visits per person, per year to see a chiropractor).
- Details about co-pays - that is, cost-sharing with your insurance company (Example: you may have a co-pay of $20 each time you visit the doctor). Remember: for new (non-grandfathered) health plans, there is no longer any cost sharing for preventive services. If you are unsure if a service qualifies as preventive, call our consumer advocates at 1-888-877-4894 (toll-free).
- The deductible, if any, that must be met before the plan will start to pay for medical care received.
- The exclusions or limitations to the policy.
- How the policy defines medical necessity and experimental or investigational treatment.
- The benefits that require preauthorization (advance permission) from your health plan, and how to get that approval.
- How to appeal decisions made by your health plan.
- The medical providers you can use.
- How the plan pays for services from an out-of-network provider.
- Note: If you have group health insurance coverage through an employer, it is generally the employer's responsibility provide you a copy of the plan or tell you where to find plan information online.
Before you decide to file an appeal, read:
- Your covered benefits in your plan's benefits booklet.
- What your health plan will not cover. You'll find this in the exclusions and limitations section. (For some plans you may need to contact your health plan directly for this information.)
Information about your benefits
Make sure you have the most recent copy of your plan's benefits booklet, which should include the specific exclusions and limitations to your plan.