It’s Up To You To Manage Your Own Health Insurance

In the Marcus Welby days, people went to Dr. Welby, and he decided what tests and treatments were necessary. Their health insurance companies, being insurance companies and not trained physicians, paid most of the tab.

Many people have the idea that managed healthcare, meaning a health maintenance organization (HMO), preferred provider organization (PPO), or point-of-service plan (POS), is an affordable form of the old fee-for-service system, but with more paperwork and perhaps more insurance company “meddling.”

People need to realize that this is a whole new system, a binding legal contract, with strict limitations, says Paula Mikrut, MD, vice president of medical affairs of Intergroup of Arizona, a medium-sized HMO with 350,000 members.

When you sign up with an HMO, you are signing a contract saying you will abide by the rules of the road and will receive only covered benefits. Not all tests, all treatments, all drugs, all doctors in town will be covered. This is a fact of life under managed care.


The first thing you can do to maximize what you get from your health plan is to choose a plan wisely. If your employer offers no choices, the following tips are even more important. If you do have a choice, it is up to you to check out the plans and see if they meet your particular needs.

The National Committee for Quality Assurance (NCQA) in Washington rates plans by a number of criteria, including access to doctors, quality of physicians, wellness and disease management programs in place (including how many people get recommended tests), and how plans treat people during and after an episode of injury or illness. Ratings can be accessed on the Web site ( Employers use this information to decide what plans to offer. You should use it to decide which plan to choose.

You can choose a plan that includes your favorite doctors, or you can choose a “primary care physician” after you get in the plan. That doctor is your key to the system, although primaries are often called “gatekeepers,” which has a connotation of a closing gate, in some cases denying you treatment or regulating what specialists you can see.

In reality, your primary can be your advocate and help you negotiate the system. The problem is that your doctor may be “serving” many different plans, with different sets of rules, and may need help to get you a good result. That’s where you come in.


The first thing you need to do (really, don’t wince) is read your Evidence of Coverage booklet. This is your insurance policy: It tells you what your health plan will cover and what it will not. You need to know what hospitals you can go or be taken to, what labs will do your tests, when you can call an ambulance, what to do if you get sick on weekends, what home care will be allowed, what medical devices such as wheelchairs are paid for, and dozens of other important things.

“It’s only human to ignore conditions until they become urgent,” Dr. Mikrut says. “Many people don’t pick a primary until it’s 3 in the morning and they’re sick. But you have a diminished ability to deal with your health plan under such conditions.”


“File health insurance records just like you would keep all the tax records for your house,” advises Mikrut. “If you keep immunization records for child, keep a chronology of significant health events and doctors’ visits for everyone in your household — adults too. Know when you had your last tetanus shot, your last mammogram.” Although many plans will send you reminders of needed visits, ultimately it’s your job to make your own appointments.

Unless you have “open referral,” your primary must recommend and approve a visit to a specialist. Most plans allow such visits if medically reasonable, and almost all will allow a paid second opinion.

As for pharmacy, as everyone knows by now, each managed care company has a “formulary” of approved drugs. If you take a medicine “off the formulary” or a brand name, you will probably pay more. Talk to your doctor, and ask about alternative medicines that are on the formulary. Some plans, including Intergroup, issue a booklet to patients with all the drugs on the formulary: Hand it to your doctor and discuss selections.

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