Think Like a Health Plan

In one of my lives (I have a few), I serve as the medical director for a commercial health plan. My duties involve developing policies and reviewing claims. It’s the greatest job on earth if you love evidence-based medicine (which I do!). And it connects perfectly to another life: teaching EBM at the University of Minnesota, which I’ve been doing since 2004.

I’m pleased to return to St. Joseph’s Hospital, my former employer and postgraduate alma mater, on August 20th to discuss health insurance with the family residents.

This post contains my key teaching points and didactic materials.

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Suggested Thought Process

1. Is the health care service a covered benefit? (cf. benefit plan)
2. Does the carrier have a policy concerning the health care service?
3. In the absence of a specific policy, is the health care service medically necessary?
4. Does the member (patient) and/or evidence meet criteria?

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Benefit Plan

At a very high level, benefits are determined by the member’s benefit plan. Eligible services are subject to the plan’s terms, as often summarized in medical policies. Excluded services are not eligible for coverage and cannot be funded by the plan (doing so would violate a contact with the plan’s owner).

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Medical Policies

• Aetna
• Anthem
• BlueCross BlueShield of Minnesota
• Cigna
• HealthPartners
• Medicare
• PreferredOne
• UCare

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Medical Necessity

• BlueCross BlueShield of Minnesota (medications)
• BlueCross BlueShield of Minnesota (technologies)
• HealthPartners
• PreferredOne

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Group Exercise

• Benign skin lesion removal [Aetna]
• Breast reduction mammoplasty [HealthPartners]
• Continuous glucose monitor [BlueCross BlueShield of Minnesota]
• Esketamine intranasal (Spravato) [Cigna]
• Gender confirming surgery [UCare]
• Genetic testing for hereditary hemochromatosis [Aetna]
• Lipoma removal [PreferredOne]
• Non-emergent ambulance services [Anthem]

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