Knowing your plan’s rules – and your rights and responsibilities under those rules – can help you make the best use of your plan. It also can save you money and help you get the care you need.

You get a lot of information about your managed care plan when you enroll. The member handbook and benefits list explain the benefits – the kinds of treatments and services your plan pays for. Keep this material handy so you can refer to them when you have questions. Read the plan newsletter, if there is one. It keeps you up to date on any changes in your plan.

A health plan contract provides a legal definition of plan benefits. If you are in a managed care plan through your job, the contract may be between your employer and the health plan. You may need this if you have a serious problem with the care or services you get from your health plan.

The Rules

Your membership materials provide information about:

Costs and Benefits

Find out which benefits your plan pays for and which it will not. Find out how much you need to pay for each doctor visit, for prescription drugs, and for medical equipment. Learn if you pay a monthly cost (premium) or a deductible amount for prescription drugs, hospital care, or any other covered service. (Your deductible is the amount you pay before your plan begins to pay.)

Member Services

Find the telephone number for the member services department of your health plan. Call this number with questions about how to file a complaint, the health plan rules, costs, and benefits.

Be sure to tell the member services department of any changes in your address, phone number, job or family life that may affect your coverage.

Practice Protocols

See if your plan recommends doctors follow “practice protocols” or “treatment guidelines” for certain chronic diseases and other illnesses. These guidelines usually are based on standards of care set by medical experts. You are more likely to get good quality care if your doctor follows these guidelines.

Lifetime Limits

Is there a lifetime limit on how much your health plan will pay for your medical care? Many health plans pay no more than $1 million during your lifetime. This is often determined by your employer.

Out of Network Care

Know if and when your plan pays for visits to doctors and hospitals that are not part of your plan’s network. This is sometimes called going “outside the network.” You might need to pay all or a percentage of the doctor’s or hospital’s fee if you go out-of-network for care.

Your Rights

If you know your rights, you can stand up for yourself and protect yourself from an unfair plan decision.

• Read through the plan materials for information about what you can do when your plan or your doctor makes a decision you don't agree with.
• Talk with someone in the member services department to find out how to appeal a plan decision you feel is unfair. For example, how to appeal your plan’s decision to stop paying for your medical treatment.
• Your state insurance department can tell you about federal and state laws that protect your right to health care in managed care plans. Your state insurance department may help you file a complaint.

Your Responsibilities

People today take more responsibility for their health than they did 20 years ago. They are more active, eat better, and work as partners with their doctors. Taking responsibility for your health can mean a healthier and happier life. Here are some ways to do that:

• Learn healthy habits. You are responsible for what you eat, how much exercise you get, whether you smoke and following your doctor's advice when you are healthy and when you are sick.
• Call your plan doctor or your plan's help line if you need advice about medical problems.
• Go to the nearest hospital emergency room if you have a life-threatening or very serious health problem. Be sure to call your health plan as soon as possible.
• Get the recommended preventive care such as screenings for cancer or shots to prevent disease, like a flu shot. If you health plan has them, take advantage of any classes to help you quit smoking or develop a healthy diet.

Additional Resources

U.S. Agency for Healthcare Research and Quality (AHRQ)
Read "Checkup on Health Insurance Choices" and "Choosing and Using a Health Plan," from this federal agency.

HealthCareCoach.com
Learn the basics about HMOs and PPOs.