to Evaluate a Health Insurance Company
© Patricia Foote, May
- Does the plan provide for regular, preventive
- Do preexisting medical conditions prevent
full coverage? How long do you need to be enrolled before a preexisting
condition will be covered?
- Does the plan allow you a choice of physicians?
- Are there any co-payments?
- Which services need pre-approval? Who
will authorize this pre-approval and how far in advance of the
procedure does it need to be done?
- How are participating physicians paid?
Is there a capitation policy? (Capitation: a method of
payment for health services in which a physician or hospital
is paid a fixed per capita amount for each person served, regardless
of the actual number or type of services provided to each person.)
- Are there "gag clauses" that
keep a doctor from recommending treatment or criticizing the
- Can you contact specialists directly
or do you need a referral?
- Does the plan provide a prescription
- Does the plan include full reproductive
health and pregnancy care?
- Does the plan provide treatment for mental
health problems? Is there a limit to the number of visits?
- What are the deductibles and/or co-payments?
- How are treatment decisions reviewed?
- Is there an appeals process if a service
is denied and what is it?
- Are genetic tests covered?
- What is the policy on experimental drugs
and clinical trials?
- What are the restrictions/benefits for
- Is coverage nationwide/worldwide?
- What is the "medical-loss ratio"
(the amount that the provider actually spends on medical care)?
- Does this policy contain a catastrophic
- Is there a life-time cap on reimbursement
payments? What is it? What services are not covered?
- Is the insurance company registered and
accredited? Contact: Group Health Association of America, 1129
20th St., N.W., Suite 600, Washington, D.C. 20038.
- Read the review of managed care in America
done by the National Committee for Quality Assurance.
- Read "What Cancer Survivors Need
to Know About Health Insurance" published by the National
Coalition for Cancer Survivorship.
- Add your own questions ....
Collecting Health Insurance Benefits:
- Send your claims in on time. Most insurance
companies have a time limit for submitting claims.
- If you are too tired to work on bills
yourself and noone else can do it, consider hiring a health claims
processing service to do it for you.
- Keep copies of all bills and correspondenced
with the insurance company.
- Submit bills in the proper order i.e.
first to the primary insurer and then to the secondary insurer.
Foote is a trainer for Stanford University's "The Chronic
Disease Self-Management Course" and is the author of How
Are You? Manage Your Own Medical Journey, available from
or local bookstores.
Long Term Care