Help DeskInsuranceInsurance GuideSelecting a Policy

2.4. Selecting a Policy

Guidelines for Selecting a Health Insurance Policy

Insurance companies are businesses; their goal is to make money. Your responsibility is to be an educated, informed consumer who is able to make appropriate selections for your health insurance coverage. The National Committee of Quality Assurance, a non-profit organization has developed a "Health Plan Report Card" that can assist you in your decision.1 You may obtain a consumer guide for your state (online resource only) at

Insurance companies are regulated by each of the states in which they do business. Generally, a State Insurance Commission oversees these regulations. However, self-insured plans are not regulated by the state; the federal law known as ERISA or Employees Retirement and Income Security Act regulates them. The employer of the insured runs self-insured health plans. It is important to know if your employment-derived health insurance coverage is a 'self-insured' plan. This will be useful and important information when negotiating with your insurance company for disability-related coverage.

1 Health Plan Report Card. National Committee for Quality Assurance. or 1-888-275-7585

Personal Considerations, Questions to Ask, and Insurance Definitions are important contributors to your selection process: (Considering your own circumstances, use these sections to identify and prioritize your needs and health goals)

List your personal considerations:

  • What are your health practices that promote your health and well-being as a person with a SCI/D

  • Do you have any existing chronic conditions in addition to your SCI/D

  • What specialists provide your care, i.e. physiatrist, urologist, cardiologist (list your doctors, the hospital(s) at which they have admitting privileges and the plans in which they participate)

  • How often is it necessary for you to be seen by each specialist

  • What rehabilitation therapies do you need and how frequently, such as physical or occupational therapy

  • Do you need personal assistant services; if so, how many hours daily or weekly

  • What durable medical equipment, rehabilitative, assistive and adaptive devices do you require for accessibility and independent functioning

  • Do you live near your needed health services (What is your hospital preference)

  • How do you get to the doctor, urgent care center or hospital, when needed

  • Is your health insurance only for yourself or do you have beneficiaries

  • Are you employed or is seeking employment within your goals

Knowledge of lifetime caps on health insurance benefits is important information for persons living with SCI.

Questions to ask about a health insurance plan:

  • What kind of policy is this, i.e. read the description of the policy

  • Can I choose or retain a specialist (e.g. physiatrist) as my primary care physician (PCP)

  • Is there coverage for specialists including those with SCI expertise

  • Does the plan provide out-of- network referrals or standing referrals to specialists or specialty care centers

  • Are physicians' offices and related health facilities accessible

  • What services are and are not covered (i.e. its inclusions, limitations and exclusions): inpatient and outpatient rehabilitation, home health assistance, mental health care, medical transportation (This information is often in obscure places within a policy such as within definitions)

  • What are the policies regarding deductibles, co-payments, prescription and durable medical equipment coverage, long-term, community-based services

  • Are there case management services for people with SCI/D

  • Does the plan offer a help line or advice line for assistance; if so, who staffs this line

  • What are the requirements for pre-certification or authorization for preventive, routine, elective, urgent and emergency care

  • Does the plan have lifetime caps, i.e. a maximum amount of dollars that will be paid for a condition or for particular services such as rehabilitation, personal assistance or equipment needs

  • Is there a clearly explained process for you to file a complaint; are you eligible to receive reimbursement when seeking a second opinion, if and when you believe you are not receiving necessary and/or appropriate services

Understanding Insurance Definitions before Selecting a Health Insurance Plan:

  • Premium – a periodic payment (usually monthly) made to a payor (insurance company) to keep an insurance policy active; must be paid before, and whether or not, any services are actually received.

  • Deductible - an annual, out-of-pocket amount, fixed by the individual insurance policy, that the insured must pay each year before the company will begin payment for covered benefits. (If there is a deductible, you should know how much it is, if it is for the entire family or does each member of the family have to satisfy the specified deductible before the plan pays individual benefits)

  • Co-payment – a fixed amount that is required every time you use your health plan for service(s) and pharmacy prescriptions.

  • Co-insurance – a percentage of a health care service fee that must be paid by the patient; a person's second insurance program (secondary) may pay all or a portion of this amount.

  • Basic medical services - well care visits

  • Major medical plan – may include such services as dental, pharmacy, mental health, vision care

  • Pre-existing condition – an illness, disability, or disease that the insured has incurred before coverage has commenced. The passage of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) has prohibited the exclusion of individuals from coverage in health insurance plans due to pre-existing conditions.

  • Network - physicians, auxiliary services, and hospitals with which an HMO contracts to provide care to its clients.

  • Out-of-network: physicians, auxiliary services, and hospitals that are not associated with a particular plan or organization. Depending on the plan, consumers who select out-of-network services may have to pay a higher cost or the entire cost of going out-of-network. Exceptions are usually made when members of the plan are traveling out of range of the service provider network.

  • Lifetime cap (Important knowledge for a person with a SCI/D)– Maximum amount that a plan will pay for a given condition (usually $1,000,000)

    1. Inquire if a higher cap is available and the cost of this addition to the policy
    2. In self-insured plans, the employer can set different lifetime caps for different medical conditions

  • Medically necessary services - must comply with the terms of the insurance contract (policy); cannot be experimental, non-FDA approved, educational, or investigative in nature
Knowledge of lifetime caps on health insurance benefits is important information
for persons living with SCI

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