Access to Care

• Is this an open access or gatekeeper plan? If a gatekeeper plan, how are referrals to specialists handled? Once an employee sees a specialist, does he/she need to go back to the gatekeeper each time he/she needs to see the specialist again?
• If this is not a gatekeeper plan, do specialist visits need to be approved in advance?
• What procedures require pre-authorization or pre-certification? Are they the same both in and out of network? What are the penalties if these procedures are not followed? Are they the same both in and out of network? What services are excluded from coverage?
• How does the plan define "experimental procedures"?
• What are the reimbursement rules for durable medical equipment?
• What is the procedure for appeal of denied claims? Is there an opportunity for external review outside of the health plan?
• Are out-of-country services covered and to what extent?
• How are dependents residing outside of the coverage area handled?
• Does the plan offer an Internet-based platform to review information?
• What is the level of reimbursement for out-of-network benefits? Are they the same for out-of-area?
• When are service representatives available to answer claims questions?