Kathleen G. Kane - Pennsylvania Office of Attorney General - Protecting Pennsylvanians

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Know your Health Care Policy

The Health Care Section is often asked what a consumer can do to be more proactive about health care decisions. The most important thing is to be an informed consumer. Consumers almost always consult the internet or consumer research reports before purchasing a new car, household appliance or DVD player. Just as much time and effort should be put into understanding your health insurance benefits because health care decisions may have more far-reaching consequences than any others we make.

The first step to becoming an informed consumer is to understand the different types of health insurance policies. The most significant differences among insurance policies include:

  • What is covered
  • How benefits are accessed
  • Cost share responsibilities (deductibles, co-pays, co-insurance)
  • How coverage denials are appealed

Traditional indemnity policies allow the greatest choice of providers, and often have the greatest out-of-pocket cost. Frequently, there is a major medical component which allows the consumer to offset some of these out-of-pocket costs. The consumer must follow the plan's established procedures in order to appeal an adverse decision concerning coverage.

Managed care plans include Health Maintenance Organizations (HMOs) and Point of Service (POSs) plans. These plans require a primary care physician (PCP) who acts as a "gatekeeper," by providing written referrals to other in-network providers and facilities. The consumer is responsible for a co-payment at the time of service. Consumers have limited ability to "self-refer." These plans are subject to specific statutory requirements including appeal rights.

Preferred Provider Organizations (PPOs), do not require a gatekeeper, but do include a network of "preferred" providers with which rates are negotiated. The consumer typically has greater freedom of choice than with a managed care plan, but can minimize his out-of-pocket costs by receiving services from a "preferred" provider. The consumer usually has a set co-payment at the time services are rendered. The consumer may not have the same appeal rights mandated for managed care plans.

If you experience a problem with your health care that you are unable to resolve, contact the Office of Attorney General's Health Care Unit at 1-877-888-4877 between 10 AM and 3 PM or call 717-705-6938 between 8:30 AM and 5 PM.