Consumer Reports’ Shop Smart: Your guide to the new insurance rules

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The new health care law has im­proved a lot of things about health in­sur­ance, ac­cord­ing to Con­sumer Re­ports. You can’t be turned down or charged ex­tra if you have a pre-ex­ist­ing con­di­tion, all types of ba­sic health ser­vices are cov­ered, plans can’t cap an­nual or life­time ben­e­fits and most pre­ven­tive care is free.

But in­sur­ance can still be com­pli­cated, and if you don’t fol­low the rules you can run into “got­chas” that can cost an arm and a leg.

Orly Avit­zur, med­i­cal ad­viser to Con­sumer Re­ports, lists five ques­tions you need to an­swer be­fore you see a doc­tor.

1. Is he or she in my plan’s net­work? That seem­ingly sim­ple ques­tion is any­thing but. The list on the health plan’s web­site might not be up-to-date, so it’s best to dou­ble-check first with the doc­tor’s bill­ing of­fice with the ex­act name of your plan.

2. What are the lim­ita­tions and ex­clu­sions? All plans have to cover “es­sen­tial health ben­e­fits,” such as phy­si­cians, hos­pi­tals, drugs, ma­ter­nity care, men­tal health care, tests, emer­gency care and re­ha­bil­i­ta­tion, but spe­cif­ics might vary. You’ll find those de­tails in the stan­dard­ized Sum­mary of Ben­e­fits and Cover­age form that all plans must sup­ply. Look to see if any ser­vices have lim­ita­tions (such as a ceil­ing on phys­i­cal ther­apy vis­its) or aren’t cov­ered at all (such as acu­punc­ture, den­tures or hear­ing aids).

3. Do I need a re­fer­ral or prior au­tho­ri­za­tion? With many HMOs, you need to get ap­proval from your pri­mary care phy­si­cian to see other doc­tors or ob­tain cer­tain tests or pro­ce­dures. If you don’t, the plan won’t pay. Don’t wait un­til the last minute, be­cause of­fices are in­un­dated with re­quests.

4. Will this test be cov­ered? A com­mon rea­son for a claim de­nial is that an in­sur­ance com­pany deems a ser­vice “not med­i­cally nec­es­sary.” You can save your­self an un­wanted bill by check­ing ahead of time with the in­sur­ance com­pany and your doc­tor’s bill­ing of­fice. Keep de­tailed notes on whom you spoke with and what they told you.

5. How will my med­i­ca­tion be cov­ered? Every health plan has its own for­mu­lary, or list of pre­ferred drugs, typ­i­cally or­ga­nized into as many as four tiers in as­cend­ing or­der of price. Tier 1 usu­ally in­cludes ge­neric med­i­ca­tion. You’ll prob­a­bly be re­quired to pay more for a pre­scrip­tion when a higher-tier brand-name prod­uct is dis­pensed. When start­ing a new drug, check your plan’s for­mu­lary to see what tier it's in. If it’s ex­pen­sive, ask your doc­tor or phar­ma­cist if a sim­i­lar drug in a lower tier would work as well.

Pay­ment terms

You’ll pay your share of health care costs in the fol­low­ing ways.

1. Out-of-pocket limit. The most you’ll have to spend from your own pocket for med­i­cal care in the pol­icy year. Once you hit that limit, your health plan will pick up 100 per­cent of any ad­di­tional costs un­til year’s end. The max­i­mum al­low­able “OOP” for 2014 is $6,350 for an in­di­vid­ual and $12,700 for a house­hold.

2. De­duct­ible. The amount you must pay for cov­ered ser­vices each year be­fore your in­sur­ance kicks in. Details might vary; one plan might have a sin­gle de­duct­ible, while an­other might have a sep­a­rate one for pre­scrip­tion drugs. With some plans, not all ser­vices are sub­ject to the de­duct­ible.

3. Co-pay­ment. A flat amount (for ex­am­ple, $20) you pay for a cov­ered health care ser­vice.

4. Co­in­sur­ance. Your share of the cost of a cov­ered ser­vice. With 20 per­cent co­in­sur­ance, for in­stance, if a CT scan costs $1,000 and you’ve met your de­duct­ible, your share of the cost will be $200.

By the ed­i­tors of Con­sumer Re­ports (www.con­sumer­re­p­

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