Basic Use & Coverage: Health Insurance Plans

For many people health insurance is the most important benefits to be received from an employer. This is especially true considering the fact that more than 46 million American people do not receive basic health insurance (2006 statistics). Sometimes the language used to describe a health plan may be unfamiliar to the applicant; here are some important terms that must be known in order to have a complete understanding of the policy coverage.

Managed care refers to the process where somebody checks and controls the use and the need that people have over medical services. Insurance companies usually manage this function, and in some cases they contract other enterprises whose specialty falls in this field, which then takes control in this area. These controls are called ‘utilization reviews’ and they are carried on by nurses and utilization reviewers or case managers.

For example, psychiatrists may need to consult case managers in order to discuss a patient’s treatment coverage. Utilization reviewers are trained in this area and patients only can ask for a revision in punctual cases. Preferred providers are groups of doctors or social workers that accept payment from the insurance company. If the patient decides to go to a professional who is not added to the list, it is possible that the insurance will not pay for these services.

This same situation may occur when the patient receives attention in a medical center that is not on this list, in this case the patient becomes responsible for the bills. But even when taking services from the listed professionals and centers, the reviewers watch medical histories and treatments very carefully.

Another change between policies is the variety and quantity of the services covered by the different plans. Some time ago policies only covered the basic expenditures concerning medical assistance – medical visits and clinical admissions, but nowadays the insurance might cover services such as home visits or even baby-sitting services in case of sick children. For insurance companies these services might even mean saving money on clinical bills, and that is the main reason for their availability.

It is very important for people to understand how good the coverage is for their actual plans because it puts them in a better position to choose the appropriate plans, especially for the children’s needs. Policy holders can face several moments when they find that the policy does not cover certain services that might become very necessary, and many times these professionals are the ones that help patients to get the coverage they need.