Whether you’ve chosen a new health plan for the new year or you’re sticking with one you’ve grown used to, now’s a good time to review your coverage and the rules you’ll need to follow to get the most out of your benefits. These suggestions can help get you started.

Be Informed
Start by taking a close look at the summary plan description (SPD), which you should have received from your human resources office, health plan administrator, or union representative.

This document is the key to understanding your benefits and rights. For instance, it should tell you when you will be charged a copayment, how your dependents are covered, the amount of your deductibles, and the details of your preventive, vision, dental, and well-baby coverage.

Follow the Rules
Most people who have health insurance through their workplace are enrolled in managed care plans that are likely to have some variation on the following constraints:

• Stay within your plan’s list of network doctors and hospitals. If you don’t, you may not be eligible to receive any reimbursement for services or you may receive a lower level of payback.
• Ask for a referral. For maximum benefits, you may have to ask your primary care doctor for a referral before seeing any kind of specialist.
• Get preauthorized. Unless it’s an emergency, your physician may have to preauthorize hospital stays, surgeries, or expensive tests ahead of time.
• Stick to your plan’s drug formulary. You’ll pay more for filling prescriptions that are not on this list of approved drugs. You may have different copayments for generic drugs and for the plan’s preferred and nonpreferred brand-name drugs.

Embrace Prevention
As of 2010, new health insurance plans have to cover the following preventive services without requiring you to pay a copayment or coinsurance to meet your deductible:

• Screenings for high blood pressure, high cholesterol, colorectal cancer, depression, type 2 diabetes, and HIV
• Standard adult immunizations for hepatitis, human papillomavirus, shingles, flu, measles, mumps, rubella, meningitis, pneumonia, tetanus, diphtheria, and pertussis
• Preventive screenings for women for domestic violence, osteoporosis, sexually transmitted diseases, mammography, cervical cancer, and well-woman services for women younger than age 65
• Services for children, including screening for alcohol and drug use, autism, behavioral problems, obesity, lead exposure, and depression

Look Toward the Future
Starting in 2014, all health plans must cover pre-existing conditions for children and adults. At present, children’s pre-existing conditions may or may not be covered depending on your policy.

Understanding the details of your health care policy can be challenging. Contact your plan administrator if you have questions about your coverage.

For more information, visit the U.S. Department of Health and Human Services at www.healthcare.gov.

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