PART I: Understanding your health coverage
Health insurance is a monthly expense that protects an irreplaceable asset your life. Understanding the language of insurance can help you utilize the benefits and anticipate out-of-pocket costs, alleviating future stress and confusion.
Premiums are the periodic payment to an insurance company or a health care plan for health or prescription drug coverage. The lower the premium cost, usually the more financial responsibility one will assume through out-of-pocket costs.
Out-of-pocket costs are expenses not covered by your insurance premium. Out-of-pocket costs include deductible, copay, and coinsurance. Often, insurance plans have a deductible that must be met first. A deductible is the amount you must pay before your insurance begins to pay on your behalf.
Insurance plans will also have a co-pay and co-insurance. Co-pay is an amount you may be required to pay as your share of the cost for a medical service or supply. Usually it is a set amount paid at the time of service and does not apply to your deductible. Co-insurance is the amount, usually a percentage, that you may pay as your share of the cost of services after the deductible has been met.
Co-pay and co-insurance expenses will continue until you meet the out-of-pocket maximum. The out-of-pocket maximum is the limit you will pay out of pocket in a year. This fixed amount includes the yearly deductible, co-pays, and coinsurance. Monthly premiums are not included in the out of pocket maximum total and it starts over each year or anniversary for some with employer insurance. Medicare or Marketplace health insurance plans operate on the calendar year and begin Jan. 1.
Review your explanation of benefit statements on a regular basis. Explanation of Benefits, EOB, is a summary of health care charges that your insurance company sends you after you see a provider or get a service. It is not a bill, but a record of the health care you or individuals covered on your policy received and how much your provider is charging your insurance company. You will be able to keep track of what is applied to your deductible, copay, coinsurance, out of pocket maximum, and determine your financial responsibility. Reviewing your statements is another way to detect insurance fraud and help decrease health costs.
PART II: Using your health insurance
Staying healthy increases the chances youll be there for your family and friends for many years to come. Using your health coverage when you are sick and when you are well, will help you live a long, healthy life. Health coverage pays for provider services, medications, hospital care, special equipment, annual wellness visits, and certain screenings.
While benefits between insurances may be the same, insurance plans differ in who they contract with as service providers. This can make a difference in how much you are financially responsible for and what is counted toward your maximum out-of-pocket total.
A provider is a health care professional. This may be a doctor, a nurse practitioner, behavioral health professional, or another health care professional you see. Your primary care provider will be the provider you see the most, they will get to know you and help you keep track of your health over time. They make sure you get the care you need to keep healthy. They may also talk with other doctors and health care providers about your care and refer you to them. With some health plans, you must see your primary care doctor before you see any other health care provider such as a specialist. Specialists focus on a specific area of medicine or a group of patients to diagnose, manage, prevent, or treat certain types of symptoms and conditions.
You want to be sure to use providers that are in your network. Network, also known as in-network, represents the facilities, providers, and suppliers your health insurer or plan has contracted with to provide health care services. Using in-network providers usually costs you less. Out-of-network providers are those who do not contract with your health insurer or plan to provide services to you and you usually pay more to use them. To determine providers who are in your plans network, call the companys customer service line to request a list, go online to the companys website, or utilize your insurance handbook.
Your health insurance may require preauthorization for certain services before you receive them, except in an emergency. Preauthorization is a decision by your health insurer that a healthcare service, treatment, prescription drug, or durable medical equipment is medically necessary. Preauthorization is not a promise your health plan will cover the cost.
Emergency services are covered by your health insurance plan if you are injured or very sick no matter if the facility is considered in or out of network. There is a difference between visiting your primary care provider, convenient care, and emergency department, such as cost, time spent waiting for care, and follow up. It is best for you to get routine care and recommended preventative services from a primary care provider.
