Managing your health insurance can be difficult. Whether you have public health care benefits (AHCCCS) or private insurance, many of the struggles are the same. This guide will give you general information and tips to help you get the services that you need.
What Can You Do To Get The Most Out Of Your Health Care Coverage?
- Think about your role differently
- Stop being a patient
- Become health care consumer and self-advocate
Get Organized
This is the most important thing to do. If you cannot find anything or know who you spoke to, you will lose out.
START A FILE. Keep all your papers together in a binder or drawer so you know where to find them. Put all papers about the same service in a folder.
KEEP A COPY OF EVERYTHING. Keep copies of all the letters you receive from your health plan. Also, keep copies of all the letters and other records that you send to the health plan, especially letters written by your doctor or health care provider. Health plans are big companies and it is easy for your papers to get lost.
KEEP A RECORD OF PHONE CALLS. You will talk to many health care providers and health plan staff. When you call about your health care, have your insurance card nearby with your member and group number. Write down the date, name of who you spoke with, their title and what was discussed.
KNOW DEADLINES AND FOLLOW THEM. As soon as you receive a letter from the health plan with a deadline, write it down on your calendar. Take these deadlines seriously. If you do not meet a deadline, you may be unable to get the service you need. For requests to your health plan:
- Make all requests in writing.
- Keep a copy.
- Keep proof of when and where you sent a request. Send important documents by certified mail, return receipt or by fax with confirmation sheet.
MAKE A LIST OF YOUR PROVIDERS. Keep a list of the names, addresses and telephone numbers of your health care providers. This will make your life easier.
Knowledge is a Power: Know Your Policy
To be a good consumer you must know your product. Know what services your health plan is required to provide. If you have AHCCCS, you should receive comprehensive health care services that are outlined on the AHCCCS website.
If you have private insurance, your benefits will depend on what your policy covers. For private insurance, read the member health plan handbook. You should know this basic information about your health insurance:
- What services are covered?
- What doctors or providers can I go to?
- When do I need a referral?
- When do I need a prior authorization?
- How much do I have to pay out of pocket?
In addition to knowing about your policy, you should also know about your medical condition. Ask your doctor and research what choices are available for treatment of your condition. Comparing what is available treatment to what is covered by your health plan will help you get the most out of your health insurance.
Get Your Doctor on Your Side. Prevent Denials and Appeals
The best defense is a good offense. You can prevent a denial and the headache of an appeal if you get your doctor involved early in the process. Your doctor and other health care providers are key to helping you get the health care you need. They are busy so you must ask for the help you need. Here’s how:
Letters of Medical Necessity – The most common reason a health plan will deny a service is that they do not have enough information about you and the service you need. To avoid this problem, ask your doctor or health care provider to write a letter of medical necessity and send it with the request for service.
The letter should have:
Your medical condition with exact diagnosis.
- How long your condition will last.
- Why you need the service and a description of the service.
- What health problems will occur if you don’t get the service.
- What other treatment or services were tried, if any, and why they did not work.
The doctor can ask the health plan to call him or her with any questions about the letter. You can also get letters from any health provider or other professional who knows about your condition and why you need the service.
- Medical Records – Your medical records can help prove to the health plan why you need the service. Ask for copies of your medical records. Ask your doctor to send in copies of medical records that support their letter of medical necessity.
- Consultation with Health Plan Doctors – Decisions on whether a service is medically necessary are usually made by a doctor at the health plan. If your service is denied, call the health plan and find out what doctor or professional made the decision to deny your service. Ask your doctor to call the health plan directly to discuss your condition and the service you need. Sometimes the health plan will change its mind after discussing your situation with your doctor.
Getting your health care provider involved early on will avoid denials and appeals and get you the services you need faster.
Be Assertive and Don’t Give Up
Self-advocacy means speaking and acting for yourself. It means deciding what is best for you and taking charge of getting it. It means standing up for your right to the health care you need. You will be more likely to get what you want if you are assertive. Being assertive means that you talk respectfully and professionally to others and communicate effectively. Don’t be someone who chooses to fight or argue instead of talking calmly about the problem. Arguing will get you nowhere. One example of being assertive is to ask to talk to a supervisor at the health plan if you are not getting what you need from the health plan representative.
Your health is important and you deserve it. If you are denied, file an appeal. Just by filing an appeal, you greatly increase your chances of the health plan saying yes to the service you want as it will force them to take another look at your claim. Ask for help from family members, friends or other advocates when you need it. Sometimes just taking a family member or friend to an important appointment or meeting will make a big difference.
Resources
- Disability Rights Arizona (DRAZ)
- Arizona Health Care Cost Containment System (AHCCCS)
- Arizona Department of Insurance
- Health Care Advocacy Assistance
