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April 27, 2014

Consumer Reports: Your guide to the new insurance rules

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

Dr. 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. Many practices participate in more than a dozen insurance plans. 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.

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