The Fine Print of Health Insurance
Terms and conditions? Who would ever read those? As it turns out, however, it’s imperative that you understand what is in your insurer’s fine print.
To start off, we must note that this can vary depending on your health insurer and plan.
The most important part of health insurance is what it covers. You can often find coverage guidance and costs in the Evidence of Coverage (EOC) provided by your health insurer. Since the document can be 200–300 pages long, we’ll focus on the sections that are important.
The primary function of the document is include information about limitations to your coverage. One of the common limitations you will find in the fine print for health plans is whether or not something is medically necessary.
In order to figure out if something is deemed “medically necessary”, you can refer to your health insurer’s Medical Guidelines and Clinical Practice Guidelines (the name may vary by insurer). You can also look at Medical Policy and Utilization Management Guidelines to determine whether equipment, procedures, or services are considered medically necessary. Often times, treatment is only covered under very specific instances.
This is why we encourage reading the fine print and confirming that your insurer will actually cover your medical bills. You don’t want to incur a medical bill that won’t be covered because of some fine print.
Other things to look for in your insurer’s fine print: out-of-network hospital services, what is covered in the event of an accident, and treatment for conditions that was the result of non-covered services — for instance, cosmetic surgery causing an infection.
Even if your insurer says no to covering a medical service, you can appeal that decision. Consult your EOC for your appeal and grievance rights and information about government assistance from a federal Independent Review Entity.
If that sounded like a lot of jargon and cumbersome fine print, that’s because it is.
If you are a patient signed up with Cure’s platform, you can click on My Benefits to see how much you will have to pay for services. In this example, all the numbers represent the maximum cost for each type of care (primary, urgent, and emergency).
While Cure is not an insurance company, we help self-insured businesses effectively run their own health benefits plans through our platform. In our view, reading a few numbers on Cure’s My Benefits page is easier than a 200 page Evidence of Coverage.
