How well do you understand how your health plan works? According to a report in the March/April 2001 issue of the journal, "Health Affairs," less than 1/3 of the people surveyed correctly answered four questions about the requirements of their plans. The study, based on interviews with almost 11,000 privately insured people, compared consumers' answers to questions about plan requirements from information that researchers obtained directly from the health plans. The four plan requirements used to quiz consumers were 1) whether the consumer must choose from a provider network; 2) whether the plan pays any of the cost of out-of-network care; 3) whether the consumer must sign up with a primary care provider; and 4) whether the consumer must get a referral for specialty care. The researchers concluded that the consumers surveyed generally believed that their plan was more restrictive than it actually was.

Provider network

Of the four questions in the survey, consumers were most likely to understand whether or not their plan had a provider network. About 80% of individuals surveyed correctly answered this question.

If your health plan has a provider network, your insurance policy or certificate of coverage will explain the procedures you are required to follow in order to receive covered benefits. You will also receive a provider directory, which lists the hospitals, doctors, and other providers in the network. You should receive an updated provider directory annually.

Before making an appointment with a doctor, check the most current provider directory to determine if the doctor is associated with your plan. Be aware that doctors may leave the network during the year. The agreements between your health plan and the network providers are separate from your health insurance contract. Therefore, you should also call the health plan's customer service department or ask the doctor's staff when you make an appointment to verify that the provider is still part of the network.

If the doctor you are seeing leaves the network during the year, you may be able to continue your treatment with that doctor for a period of time. Managed care plans in Wisconsin are required to allow you to continue care with your primary care provider until the end of the plan year and to allow you to continue treatment with a specialist for up to 90 days. If your doctor leaves the network, your health plan should provide you with specific information about your options.

Out-of-network care

The second question in the survey asked consumers whether their health plan would pay any of the costs if they went to an out-of-network doctor without a referral. Almost 70% of the consumers surveyed answered this question correctly.

Point-of-Service plans and Preferred Provider Plans are managed care plans that allow individuals to choose any provider for most covered services. However, you generally must pay higher deductibles and co-insurance amounts for services from out-of-network providers.

If you are covered by a health plan that provides out-of-network coverage, it is important to review all of your plan materials so that you understand any restrictions that may apply. There may be some benefits that are only available from network providers. For example, many preferred provider plans will only pay for routine physical examinations and other preventive services if a network doctor provides them.

It is also important to be aware of the additional cost you may have to pay if you choose an out-of-network provider; this can be a substantial amount. Find out if there is an additional deductible amount, and how much additional co-insurance you must pay. Many health plans require you to pay an additional 20-30% of the provider's charges if you see an out-of-network provider. If you are having an expensive procedure, this can be a large amount of money. You may also have to pay an additional amount if the out-of-network provider charges more than your health plan's allowed amount. Most health plans limit the amount allowed for a service to a "usual, customary, and reasonable amount." This is based on the amount all health care providers in your geographic area charge for a specific service. If your out-of-network provider charges more than this amount, you will be responsible for paying the difference. The agreements between your health plan and network provider generally requires the network provider to accept the health plan's allowed amount and only bill you for any deductibles or co-insurance amounts.

Primary care provider

About 72% of the consumers surveyed knew whether or not they were required to choose a primary care provider for routine care.

The primary care provider is the health care professional that you choose to help you manage your health care. He or she provides routine services and refers you to a specialist when necessary. Because your primary care doctor will be responsible for managing all of your health care, it is important for you to establish a good relationship with him or her so that you can discuss all of your concerns.

Managed care plans in Wisconsin must allow you to choose a physician specializing in family practice, internal medicine or pediatrics as your primary care physician. Some plans also allow you to choose other types of specialists for your primary care. And some health plans allow you to choose a clinic as your primary care provider rather than an individual doctor. These plans allow you to see any doctor in your primary care clinic for your health care needs.

By Barbara Belling
Office of the Commissioner of Insurance