Your health benefits manual, insurance representative or the health plan manager at your place of employment should be able to answer the following questions.
• What is the effective date of the policy? In other words, when does your coverage begin?
• What is your deductible? This is the amount you need to pay before your insurance plan starts paying the
rest. Only medical care received as a benefit under your policy is calculated against your deductible.
Non-covered benefits that you pay yourself do not count.
• Do you have a stop loss? This is the amount you must pay out of your own pocket before your insurance
pays at 100 percent.
• What percentage of billed charges is paid by your insurance? Some policies pay 80 percent or 90 percent of
some costs. Others might be paid only at 50 percent. Look carefully at your policy booklet.
• Do you have coverage for home care, nursing visits at home, private duty nursing (24-hour care) and care at a
skilled nursing facility or convalescent hospital? Most insurance companies cover only skilled care. Custodial
care—such as housekeeping, bathing, laundry, assistance to the bathroom or other activities— is not usually a
covered benefit.
• Does your plan cover hospice care?
• Does your insurance provide coverage only if you go to contracted providers?
• Is authorization required for doctor's visits, hospital admissions or outpatient testing?
• Are there any waivers that would preclude payment for treatment for your condition? This might include
prior treatment (within one year for, example) for the same or a similar condition.
