< Return to Report Index
Next Section >

CHECKLIST FOR DIAGNOSING YOUR COVERAGE

Knowing your coverage will help avoid misunderstandings.  Review your plan documents and complete the following worksheet to (1) make sure you understand your coverage, and (2) have the necessary information ready in a convenient place when you need to arrange care.

MY HEALTH PLAN COVERAGE

My health plan coverage is through:

[ ]
My employer -- check if:
[ ] my plan is an insured plan; any plan denials are eligible for state external review
[ ] my plan is a self-funded plan; any plan denials are NOT eligible for state external review
[ ] A policy I bought myself
[ ] An association-sponsored policy (such as through a trade, civic or educational organization)
[ ] Other: _______________________________


My health plan is a:
[ ]
Health maintenance organization (HMO)
[ ]

Preferred provider organization (PPO)
[ ] Point-of-service plan (POS)
[ ]
Traditional indemnity (also known as fee-for-service)


Plan number to call if I have a problem: _____________________________
My primary-care physician is: ________________________________________
Physician’s phone number: ___________________________________________

I need a referral from my primary-care physician for:
[ ]
Lab and x-ray tests
[ ] Gynecologist (for well-woman exam)
[ ] Gynecologist (for other concerns)
[ ] Pediatrician
[ ] Other specialist visits
[ ] Surgery
[ ] Other: __________________________________________


My primary-care physician has the following requirements for obtaining referrals:
[ ]
Requires an office visit
[ ] Requires _____ days advance notice
[ ] Other: ___________________________________________


My primary-care physician can refer me to specialists who:
[ ]
Are part of his or her group practice
[ ] Are on the health plan network list
[ ] Are outside of the health plan network only if there are no similar specialists within the network
[ ] Are outside of the health plan network
[ ] I do not need a referral from my primary-care physician


I have reviewed the Exclusions and Limitations section in my Evidence of Coverage. My health plan will not pay for, or limits, the following services:
[ ]
_________________________________________________
[ ] _________________________________________________
[ ] _________________________________________________
[ ] _________________________________________________
[ ] _________________________________________________


My plan will cover services at the following hospitals:
__________________________________________________________
__________________________________________________________
__________________________________________________________


What should I do if I need care while I am out of my plan’s service area?
For non-urgent care:

________________________________
phone:
 ______________________
In an urgent situation:
 ________________________________
phone:
 ______________________
In an emergency:
 ________________________________
phone:
 ______________________


If you have a PPO or POS plan:


Although I can use out-of-network doctors for most services, I cannot use out-of-network doctors for the following services:
[ ]
Mental health
[ ] Substance abuse
[ ] Other: ___________________________________________

If I use out-of-network providers, I will pay:
[ ]
$_______ annual deductible
[ ] _____% coinsurance for charges exceeding the deductible.

< Return to Report Index

Next Section >