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Questions to Ask Health Insurance Providers

There are many companies that offer health care plans in the United States. Most of them include a variety of different options. Insurers offer plans for individuals and families, groups, COBRA, Medicare and Medicaid plans tailored to individual state requirements. To find a plan that suits your needs, you will need to ask several questions about each.

  1. Two Essential Issues

    • Two essential issues underlie all others: the cost of the proposed plan and what it provides. In order to get meaningful answers to your specific questions, tell the provider about yourself and your needs, such as your age, gender and health history (including major illnesses). Also, specify the kind of insurance (individual, family, employee or other group) and the approximate level of coverage, such as high-end comprehensive, high-deductible, major medical, long-term or short-term. The provider will offer you various plans. You can now begin asking more detailed questions.

    Who Benefits?

    • Ask the provider to explain the plan's coverage and which circumstances could change that coverage. Determine if the plan covers children, and if so, to which age. Ask the potential provider to explain all deductibles, co-payments, annual and lifetime limits and exclusions.

    What Are the Rate Changes and Coverage Limits?

    • Ask if the provider guarantees the rate and what may trigger an increase. Find out if the provider reduces rates in response to low claims filings and if the plan has an overall annual coverage limit. Determine if there are limits to how much it will pay for different aspects of treatment, such as hospital, surgical, anesthesiology, psychiatric or emergency medical expenses. If you have an existing plan, ask if the plan covers out-of-network emergency expenses. (If you purchase a plan after September 23, 2010, which includes emergency medical service, the 2010 health law mandates such coverage). Determine if the plan pays for generic prescription drugs or proprietary drugs.

    Which Doctors Can I See?

    • Determine if the plan allows you to freely choose your doctor. If the plan limits you to a network, ask if it will pay you for a medical opinion outside of the network. Find out what recourse you have if your primary care physician will not refer you to a specialist.

    What Is the Coverage for Long-Term Care and Rehabilitation?

    • Determine your plan's coverage for long-term care, both in your home and at a rehabilitation center or hospice. Make sure that you understand all financial and term limits for long-term care, both annually and over your lifetime.

    Dispute Resolution

    • Determine what you can do if you disagree with the provider's medical or financial decision. Ask if the plan requires compulsory arbitration. Finally, ask any medical professionals you know which providers and plans they prefer, and what they can tell you about your potential provider's general reputation.

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