Understanding Your Insurance Coverage
In order to maximize the benefits of your insurance plan, it is important for you to keep a record of the name, phone number, identification, and group number of your insurance plan. You should also note who the subscriber is (you or your spouse), his/her date of birth, and social insurance number. Identify any other insurance benefits you may have, such as a separate prescription benefit card or a long-term-care policy.

If you have more than one insurance plan, determine which policy is primary and which is secondary; confusion with this matter can result in billing errors. Your insurance company customer service representative can be helpful in identifying which plan is to be billed first. Also keep up to date on your insurance; if your coverage changes in any way, notify all your doctors, medical suppliers, and pharmacists immediately so that the next time you access their services, you will have helped to prevent billing errors.

Contact your insurance company directly, and ask specific questions about your benefits. Always note the date and the person who provided the information. Remember, having your benefits described over the phone does not guarantee coverage. Your doctor may be asked to write a letter of medical necessity and complete specific forms to verify your medical condition and eligibility for whatever item or service is being requested.

Ask if your policy offers case management. Case managers either work for the insurance company or are contracted by them to monitor and advocate for patients whose costs are high or who have complicated needs. They are often helpful in cutting internal “red tape” (problems), gaining access to little-known insurance benefits, and reducing your overall out-of-pocket expenses. Case management can be activated at various stages of your illness, depending on how your insurance company has defined the benefit. Having direct communication with your insurance carrier will help you to gain an overview of your policy and remove the mystery of how your plan works.

Use the following guide when contacting your insurance company. Be sure to have all of the specific information about your insurance plan in front of you before calling. Do not hesitate to ask what certain words or terms mean.

What You Need to Know About Your Health Insurance Policy

General Questions
Is there an annual deductible?

Is there an annual out-of-pocket expense limit or maximum? If I meet my limit, does my coverage increase and to what extent?

Do I have a major medical plan? Is there an annual or lifetime maximum?

Do I need to complete any claim forms?

Am I subject to preexisting condition regulations?

Durable Medical Equipment (DME) Questions
Does my plan cover DME? What about ventilator coverage; is it under respiratory equipment or DME?

What is the percentage of my coverage?

Is there a preferred provider I must see?

Is pre-authorization or a medical review required?

Prescription Questions
Does my plan cover prescription drugs? What are the terms of this coverage, and is coverage different based on using brand-name versus generic drugs?

Is there a specific pharmacy/supplier network I must use?

Are injectable medications covered under my plan?

Is there a limit on the amount of prescription drugs I can go through on this plan?

Is there coverage for all Health Protection Branch-approved drugs, or is coverage provided only for those listed on your formulary (a list of drugs that an insurance policy covers)?

Does my plan offer a mail-order pharmacy option? How does this work?

Home Health Questions
Does my plan have home health coverage? How do I access this?

Is there a preferred home health care agency I must use?

Is there private-duty nursing coverage at home? Describe this benefit.

Does my plan offer case management? At what point does case management get involved and for how long?

Group Medical Insurance
Examine your group insurance policy carefully and call your insurance provider for detailed information. What are you entitled to?

Loss of income support: How much and for how long?

Prescription Drugs: What drugs are covered? What is the maximum? What is deductible?

Alternative Therapies: Are any, such as massage, covered? Any limitations?

Home Care: How much and how long?

Assistive Equipment: What type and what limitations?

Hospital: Private or semi-private coverage?

Are there any other benefits?