Private Health Care Coverage

What Does Private Health Care Coverage Provide?

Since companies compete in the marketplace on the basis of service, benefits and price, the range of what's available is endless. So regardless of the type of coverage—whether fee-for-service, PPO, POS, or HMO—the benefits vary to a significant extent. The more services that are covered, and the greater the choice of medical provider, the more expensive the coverage will be. In the case of JA, it's important to determine that any type of coverage will provide the services for the child in a way that is cost effective.

Examples of benefits that will be most helpful could include:

• Hospital services —inpatient, outpatient and emergency room
• Physician services—surgical, inpatient and outpatient
• Physical therapy
• Laboratory and x-ray services
• Mental health services
• Drug benefits
• Medical device benefits

Sometimes insurance companies deny payment for a medical service or product (such as medication) because it is not included as a covered service under the health plan or policy. This is why it’s important for you to make sure that a medical service is covered by your plan. All of the available benefits and the amount the company will pay for them should be outlined in the policy or contract you receive once you're approved for coverage.

If you get health insurance through your work, your employer gave you a summary of what is covered under your health plan. This is often titled “Summary Plan Description.” Since it’s a summary, it may not exactly match what is in the full plan. If you have questions about whether something is covered, ask your personnel department for a copy of its entire health plan. Ask someone in the personnel department to point you to the section that describes the medical service you have a question about, and see if it is specifically included or excluded.

The plans should also give you instructions on how to obtain medical services and/or obtain payments for them.

If you're in a PPO, POS or HMO, you may need to get a referral to a specialist through a primary care physician. If you skip this step, it could cost you your benefits.

Regardless of the type of plan, some require that you get permission before having certain procedures or obtaining certain medical products. Failing to get this "pre-authorization" could cause you to lose your benefits. So make sure you understand when you need to contact the plan for approval. Your physician’s office or the hospital where you're receiving care may help you obtain this or you may have to call your health plan. Before getting medical care beyond visits to your primary care physician, make sure you ask the following questions:

• Is this covered by my health plan?
• Are the providers I’m being referred to members of my health plan's network?
• Has my health plan authorized this?

If the answer is “no” to any of these, you will likely end up paying more out of your own pocket.