Can I go out of the plan’s network to see any doctor I want?
What you’re checking for here is whether your plan offers any out-of-network coverage. It’s usually pretty clear if this is or isn’t the case.

If I do go out of network (or stay in network), how much of the reasonable, usual and customary charge is covered?
For plans that have out-of network coverage, the amount covered (the coinsurance) will be different for in-network and out-of-network services. Naturally, plans that do this favor in-network coverage, and therefore cover more of it.

Do I need to have a Primary Care Physician to get referrals to other doctors?
This may or may not be a big deal to you. If you go to the doctor once a year for a physical and really don’t have many other medical needs, having to get a referral may not be a problem, since you’re unlikely to need one anyway. On the other hand, if you have a condition that requires a specialist, you may not want to go through the rigamarole of checking in with your PCP every time you, say, need to see the dermatologist.

What happens when I travel with this plan?
Most plans have allowances if you get sick while out of town, but not all. If you do a lot of traveling, check to see what this coverage is.

What about hospital/ER coverage?
Your plan will cover most--but not all--things related to a hospital visit. Medical treatments and such tend to be included, but if you want, say, a private room and your plan doesn’t include that in it’s coverage, you’re paying for it. Also be on the lookout for specialists who treat (and bill) you, but aren’t on your network. It’s not enough that your primary physician is on your network—if the anesthesiologist isn’t, you’ll get less coverage for that.

Are other services, such as physical therapy, acupuncture and chiropractic treatment covered?
It wasn’t long ago that these services cost you cash out of your pocket, but more and more insurers are offering coverage of these sorts of things now. Usually your health plan will cover a maximum number of visits per year, and like with doctors, will have in and out-of-network providers.

What about psychological services? Can I see a shrink? What if I go stone-cold crazy?
Most plans have psych services covered. They tend to have in and out-of-network providers, and also coverage for inpatient treatment. This can be a big factor if, say, you regularly visit a therapist, since the visits are numerous and, often, expensive (and switching therapists to . Most plans cover in-network therapist visits like a doctor’s visit: you pay a small copay each time you visit and that’s that. Out-of-network therapists are covered with coinsurance: the plan will cover, say, 70% of what they consider reasonable and customary. In both cases, there can be a maximum number of visits that your plan will cover in a given year.

Inpatient psych services are usually have a maximum number of days you can stay in a facility and still be covered (which may depend on whether the doctor and/or facility is in or out-of-network, naturally).

Is a prescription drug plan included in this plan, or is that managed by another company? What are the copays for generic and branded medicines?
Some plans outsource the prescription drug plan to another company. It doesn’t really mean anything if your plan does. The two plans work seamlessly together: one handles doctor and hospital visits, the other handles the drug store. And like in and out-of-network coverage with the doctor side of your plan, your prescription drug plan will have generic and non-generic coverage (granting more coverage, of course, to generic drugs).

Is there a flexible-spending account offered? Do I need to file claims for reimbursement, or is that handled automatically?
Automatic reimbursement is better, since you don’t want to be stuck with more paperwork. But if your plan does require you to file documentation to get reimbursed, by all means do it—filling out a form every once in a while is worth it if it saves you hundreds (or thousands) of dollars a year.

Want to Know More?

• Advice on Picking the Right Health Insurance
• The Different Kinds of Health Insurance
• A Totally Subjective Glossary of Health-Insurance Terms