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Working with Your Health Insurer: 10 Tips for Families
Information from the Massachusetts Family-to-Family Health Information Center

baby surrounded by male and female doctorsWhen you have a child or youth with special healthcare needs, your health insurer is an important partner. Below are some tips to help ensure your child is receiving the maximum amount of health services covered by your insurance.

1. Read the materials you receive from your health plan or employer. These may include your service benefit plan, a directory of network providers and other information. Some private health insurers send newsletters and health promotion materials. These can help you understand your benefits and maximize the services your child and family are entitled to receive.

2. Know your health plan’s mission, vision and/or core values statements. These statements generally include phrases about providing members with affordable, accessible care, forming working partnerships and ensuring a member’s peace of mind. These statements can work to your advantage when you are advocating for a service and/or having problems getting a service covered. It is powerful to frame your argument in the words your insurer has provided.

3. If your child has special health needs, ask your insurer for a case manager. This is a free service and can provide a single “go to” person who can help you understand your benefits and make the referral or pre-approval process easier and faster.

4. Review every EOB (Explanation of Benefits) you receive from your health insurer. Check the dates of services, service provider, amount paid and any co-payments you must pay. This helps avoid billing mistakes. It is also a good way to make sure you are not paying for services your child did not receive or for services that your policy should cover.

5. When speaking with customer service personnel or case managers, be polite. It is easier to enlist help when you’re cooperative and pleasant; no one wants to help someone who is rude or disrespectful. Even if the person is not able to help you, thank them for their time.

6. Work your way up the ladder: If customer service or your case manager can’t help, ask to speak to the person who can, such as a supervisor or department head.

7. Keep a written record of calls you make and copies of all letters you send to your health insurer. Write down the names and numbers of the people you speak with and a short summary of your discussion. If you have a problem getting a service covered, it is more effective to say, “I spoke with Ms. Smith on May 1, and she approved ….” Rather than saying, “I called a while ago and spoke with someone who told me…..”

8. Insurance companies look at the bottom line: what is the cost? For example, tell your insurer, “If you pay for speech and language therapy now, 52 visits will cost X dollars. If you don’t provide this service, augmentative communication/assistive technology will cost X dollars more in five years when this therapy is no longer an option for my child.

9. Frame your requests around medical necessity. There are tips for writing letters of medical necessity and samples letters at www.medicalhomeportal.org/issue/writing-letters-of-medical-necessity.

10. Once you have exhausted the appeals process, you can get help from the Office of Patient Protection (OPP). An ombudsman helps families understand their insurance benefits and work through external grievances with Massachusetts-based health plans. Learn more by calling the OPP at 1-800-436-7757 or visiting www.state.ma.us/dph/opp.

Do you have a health insurance advocacy strategy to share? Contact the Massachusetts Family-to-Family Health Information Center at 1-800-331-0688, ext. 210, e-mail massfv@fcsn.org, or visit us on-line at www.massfamilyvoices.org.