How do I get the most out of my health care insurance?

1. Read the materials you receive from your health plan. This may include your service benefit plan, a directory of network providers and supplementary materials. Many private health insurers send periodic newsletters and health promotion materials. These may help you better understand your health benefits and maximize the services your family is entitled to receive.

2. Pay special attention to your health plan’s vision, mission and core values statements. Often these statements include phrases about providing members with affordable, accessible care, forming working partnerships and ensuring members’ peace of mind. These statements can aid you when you are advocating for a service or having problems getting a service covered. It is powerful to frame your argument in the words of your insurer.

3. If your child has special health needs and requires more services than most children ask your insurer for a case manager or care coordinator. This is a free service and can provide a single “go-to” person who can help you understand your benefits and make the referral or pre-approval process easier and faster.

4. Review the EOBs (Explanation of Benefits) your insurer sends you. Check them over for accuracy, the amounts paid and any co-payments you are responsible for. This is a good way to avoid billing inaccuracies. It is also a good way to make sure you are not paying for services your child did not receive or for services that your policy should cover. Example: A child’s hospitalization cost $67,000. The insurance company offered to pay the hospital in full in 10 days if they would give the insurer a 3 percent discount. The hospital agreed, and the family received an EOB that stated “hospital negotiated discount” and noted a payment of $64,990. The hospital then billed the family for $2,010. Because the family had reviewed the EOB, they informed the hospital that they were not responsible for paying the difference between the full amount and the negotiated amount. Then the hospital voided the bill and, at the family’s request, issued a letter stating the family’s account was paid in full. If your child has special health needs and requires more services than most children ask your insurer for a case manager or care coordinator.

5. Keep a written record of calls and letters to your health insurer. Write down the names and numbers of the people you speak with and a short summary of your discussion. Write the information on the EOB, and file it chronologically so you can find the information if you need to refer to it again. This is one way to remind yourself about your original question and to refer back to your previous conversation. If you have a problem getting a service covered, it is more effective to say: “I spoke with Ms. Smith on June 1, 2007, and she approved … ” rather than saying, “The last time I called I spoke with someone who told me … ”

6. When speaking with insurance customer service personnel or case managers, be polite. You want these people to want to work with you. It is easier to build partnerships and get help when you’re cooperative and pleasant; no one wants to help someone who is rude or disrespectful. Even if the person was not able to help you, offer your thanks.

7. Work your way up the ladder: If the customer service or case manager can’t help you, ask to speak to the person who can, such as a supervisor or head of another department.

8. Insurance companies look at the bottom line: What is this going to cost? Make your requests in those terms, and in terms of “medical necessity.” Your health plan may have a definition or you can use the MassHealth definition, “A service is medically necessary if it is reasonably calculated to prevent, diagnose, improve or cure conditions that endanger life, cause suffering or pain, aggravate a handicap or result in illness or infirmity.” For example, tell your insurer: If you pay for speech and language therapy now, 52 visits a year will cost you $XXX. If you don’t provide this services, augmentative communication/assistive technology will cost you $XXX in five years when this therapy is no longer an option for my child.

9. When you have exhausted the chain of command within your insurance company, you can get help from the Office of Patient Protection (OPP). An ombudsman can help families understand their insurance benefits and work through external grievances once a family has exhausted the internal grievance process with their insurer. To learn more about the OPP, visit http://www.state.ma.us/dph/opp or call 1-800-436-7757.

This information was provided by the Massachusetts Family-to-Family Health Information Center, a project of Mass Family Voices @ Federation for Children with Special Needs, and developed with funding from the U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau, Division of Services for Children with Special Health Needs, grant number H84MC08005.