Negotiating the Insurance Maze

Recommended Steps:

Obtain a copy of the full (not abbreviated or summarized) explanation of insurance benefits. Read your policy carefully and thoroughly, including fine print, definitions, exclusions, etc. Click here for guidelines for selecting a health insurance policy.
Find out if you have been assigned a case manager and contact that individual; if not, request that you be assigned to a case manager or benefits advisor. Click here for more information on working with a case manager or benefits advisor. To be your own best advocate, you should educate this individual about your SCI/D and your particular needs to preserve the integrity of your body and health.
Determine the rehabilitation benefits: inquire about the number of allowed days of coverage for inpatient acute and sub-acute rehabilitation, outpatient and home health rehabilitation; is there an annual maximum number of days; is there a lifetime maximum number of days (these need to be differentiated according to the above categories of service)
Inquire about rehabilitation in a SCI/D-accredited rehabilitation facility; does this include both an in-state or out-of-state facility
Know the benefits re: durable medical equipment (DME); is there a lifetime maximum amount of dollars for DME
Select a doctor: Your choice will depend upon the type of insurance plan that you have. You will need a doctor with expertise in SCI/D; can this person be your primary care physician (PCP) or will your PCP consult with your SCI/D doctor in the management of your health care? The following will apply:
1. HMO: must use a physician who is part of the HMO
2. PPO or POS: Choose a doctor within the system; if your doctor is not on the given list, you may choose to go out of network; you will probably have to pay all or a larger portion of the fees
Contact your insurance representative for issues and/or concerns that relate to your health insurance and whenever you have been denied a service that you believe to be covered
Remember to always document/record all conversations with your insurance company: include date of the call, the reason for the call, the person with whom you spoke and the outcome of the call.
Keep all correspondence that has anything to do with your health insurance coverage! All written communications should include your Name, Insurance Identification (ID) and/or Group Number, Social Security Number and your date of birth; require that all actions regarding health benefits coverage be in writing.

Consumer Rights
Forms of Insurance
Selecting a Policy
Insurance Maze
Are You Uninsured?
Resources
Download Booklet PDF

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