Understanding Your Employment Health Insurance

Some companies provide health insurance to their employees, usually referred to as managed care plans.  When you signed up for your insurance plan, you automatically have agreed to its rules and most of the time you are vaguely informed on what your policy covers.  Here are some important rules you need to know about your managed care plan.

Managed care plans have limited doctors and hospitals

Insurance companies behind employee health care plans sign contracts with certain doctors and hospitals to care for their plan members, usually referred to as "providers."  Like you, they have agreed to follow the plan’s rules, such as you do not have to pay for consultations, lab tests, and treatments that are covered in your health insurance plan. 

Your insurance company may not pay for you if you go to a provider who is not in its network; this means you have to pay full expense.  However, the provider may also prefer to send you to a hospital that is not in the network, especially if you need surgery or have certain tests. 

If that happens, ask if your doctor can send you to an hospital in your insurance’s network.  If that is not possible, you can ask the insurance company if it will approve the use of out-of-network hospital.

Consulting with a specialist

Not all managed care plans provide coverage to seeing specialists such as ophthalmologists (for your eyes), cardiologists (for your heart), and even dentists.  Such plans would pay for your consultation with such specialists unless your primary care physician (usually your family doctor) thinks it is necessary.  If you see a specialist without a referral, you may have to pay the whole expense yourself.

Drug formulary

Almost all managed care plan has a drug formulary, or a list of prescription medicines that your health plan has approved.  If a drug you need is not on the list, you would likely to pay more for it.  If necessary, show the list to your doctor when he or she gives you a prescription.