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10 Things Your Health Insurer Won't Tell You

By Smartmoney.com

6. "Women may be better off in an HMO or PPO."
Elaine Weiss, a 54-year-old from New Jersey, discovered that her insurance company didn't cover her last pelvic exam. The reason? She had one the prior year. Although her doctor recommends she come in annually, her plan will reimburse her for a pelvic exam and mammogram only once every two years.

Her gynecologist's recommendation, however, is in line with the experts'. The American College of Obstetricians and Gynecologists recommends that women receive an annual pelvic exam and Pap smear. Women in their 40s should receive a mammogram once every two years and women after age 50 should get one every year.

Women who want to follow those guidelines without incurring out-of-pocket expenses may be better off in an HMO. Managed-care companies typically cover annual pelvic exams, pap smears and mammograms. They often pick up a portion of the cost for birth control pills too — a bonus for the women who shell out around $35 a month for this medication. Oxford Health Plans even promises to send its members friendly reminders if they miss their cancer screenings.

7. "We're more like an HMO than you realize."
In an effort to cut costs, indemnity plans are managing the care and services patients receive more than ever before. Consumers are finding more claims are rejected because they aren't deemed "medically necessary" — a term once used almost exclusively in HMO contracts. "The fact that your doctor has ordered it doesn't qualify anymore," says Kelly, the New Jersey nurse. "It is up to their doctors to decide."

Over time, the distinction between HMOs and indemnity plans has become increasingly blurred, says Larry Levitt, vice president at the Kaiser Family Foundation. "Traditional plans have introduced utilization measures that were historically found only in managed-care plans, he says.

For example, like HMOs, traditional health plans now assign hospital patients a case manager to precertify their hospital admission and review their continued stay. These managers, typically registered nurses, usually cannot reject treatment. But they can refer cases to a doctor in your plan who can deny authorization of payment.

Another familiar HMO-style feature found in traditional plans is the drug formulary — the list of medicines that a plan will pay for. When Blue Cross/Blue Shield of New Jersey sent out its list to its policyholders last year, it included a letter recommending they speak with their physicians about finding substitutions for prescriptions that weren't on the formulary.

"What has happened in the past 10 years is more customers have migrated from unmanaged indemnity to managed indemnity plans," says Allen Woolf, the medical director of Intracorp, a wholly owned subsidiary of Cigna. "This has been an industry standard that is not unique to Cigna."

8. "You better get used to a lot of paperwork."
The key to getting your medical bills covered is keeping impeccable records. Don't count on the insurance company to remind you that it owes you money.

Wilton, the schoolteacher, says she was able to resolve a dispute over her claims only by creating a spreadsheet and showing it to her insurer. With it she proved that she had indeed reached her deductible and her maximum out-of-pocket expense, and so should be reimbursed in full for her radiation therapy. "It is too much to handle when you are sick," she says. "You can't deal with it until you are well and angry." She's still waiting for the $2,000 she says the insurance company owes her.

9. "We are more expensive than you realize."
Those deductibles, co-payments and rejected claims can add up to some serious moolah. Jennifer Allen, a 29-year-old New Jersey woman, recently switched out of her traditional plan into an HMO after she decided she was spending too much on her health care. "It was strictly financial," Allen says. "The prescriptions alone would have bled me dry."

Since the late 1990s, a patient's total exposure to out-of-pocket expenses plus deductibles has spiked. According to David Zeller, who owns an insurance agency in Lynn, Massachusetts, insurance companies have been raising their deductibles at a frightening pace. As a result, he says, deductibles of $1,000 to $2,000 are increasingly common. Back in 1995, the average deductible was just $250, Zeller says.

At the higher deductibles, health insurance can amount to little more than coverage against a major illness, while routine health care is essentially uninsured. "A lot of my clients are using insurance for disasters and assume they will have to pay out of pocket for the rest of their care," says Barbara Seller, a midwife in New York.

10. "We change our rules constantly."
Traditional health plans are constantly tweaking their policies. Aetna U.S. Healthcare's Web site posts a summary of what it calls its "coverage policy bulletins." This is where it lists any changes in its coverage. During 2000, more than 200 services were revised, added or deleted. You try and keep up.

Katherine Grusenski, also a schoolteacher in New Jersey, receives an addendum to her plan every six to eight weeks. Then every year she gets a new booklet. She says she has to go through it word-by-word to make sure she has the same coverage one year to the next.

Xavier, the dental-office manager, says the only way she knows if a certain plan has made a change is when a claim is sent back with a rejection. "It used to be that crowns were covered every five years," she says. "Now they have decided a crown should last 10 years. They didn't tell anyone when they were going to do it. All of a sudden you just started getting denials."

And as if it weren't hard enough to keep track of one policy, try figuring out two policies and how they might work together. That's what you'll have to do if you and your spouse are covered both under your own plans and each other's. It's called coordination of benefits — and the upshot, according to Zarafu: "Each plan will say the other should pay."

And here's a final tip: Insurance companies sometimes make honest mistakes. They administer so many different plans for so many different employers that they can't possibly know the details of all of them. So if you've been denied a claim for something you thought was covered, call the insurer and ask to speak to a customer service rep. Have a copy of your plan ready and be prepared to read them chapter and verse. You just might be pleasantly surprised.

This story was first published on Nov. 22, 2000.

SmartMoney.com 2004 SmartMoney.

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