Health Insurance Tips
When first taking ownership of a healthcare insurance plan, it is easy to become overwhelmed and confused with new jargon, payment terms and options. At the 15-40 Connection, we want to help you understand the requirements and know how to best utilize options when taking ownership of a healthcare insurance plan.
Below are key terms to be familiar with before seeing your healthcare practitioner:
Claim: A claim is a request for payment under the terms of a health benefits plan. A claim can be submitted by a member or by a provider. A claim will go through stages such as pending and paid.
Co-Payment (Co-Pay): The amount that a plan member must pay the provider at the time of service. This amount varies depending on the specifics of a given health plan contract.
Deductible: The dollar amount that a member must pay for healthcare services before a health plan will cover eligible services. For example, if a member's deductible is $500, the member will pay that amount, out of pocket, before the health plan will cover any eligible services.
Pre-Existing Condition: A health condition (other than pregnancy) or medical problem that was diagnosed or treated before enrollment in a new health plan or insurance policy.
Primary Care Provider/Physician (PCP): A physician, usually a family or general practitioner, internist, or pediatrician, who provides a broad range of routine medical services and refers patients to specialists, hospitals, and other providers as necessary. Under some benefits plans, a referral by the primary care physician is required to obtain services from other providers. Each covered family member chooses his or her own PCP from the network's physicians.
Provider: A licensed healthcare physician, facility, program, agency, or other health professional that delivers healthcare services.
Referral: If a PCP determines that an individual requires specialized care, the PCP may "refer" that person to an appropriate specialist. A referral is often required before the plan will cover certain services.
Specialist: Provider whose practices are limited to treating a specific disease (e.g., oncologists), specific part of the body (e.g., ear, nose, and throat), or that conducts a specific procedure (e.g., oral surgery).
Helpful tips to make your trip to the doctor efficient and seamless:
- It is important not to have a lapse in health insurance, a time period where you do not have health coverage. This is important for your personal health and some insurance companies may deem you have a “pre-existing” condition because of the gap in insurance.
- Obtain your insurance card. It identifies the health plan you are in and your member number. It provides a number you can call for questions regarding your plan.
- Always carry your insurance card with you. When visiting a healthcare provider, they may ask to see your card and a state issued photo identification card to prove who you are.
- Anytime you use your healthcare plan to visit the doctor, fill a prescription or obtain a medical device, you may have to make a co-pay or pay a deductible. Refer to your plan details for specific information.
- Insurance plans may have approved providers (called an in-network provider). If so, seeing a provider outside of your health insurance network (called an out-of-network provider) may not be covered or may have an additional cost. A list of approved providers can be found on your health insurance plan website or you can contact the insurance company directly by calling the number on your insurance card.
- Some insurance companies require you to get a referral before seeing certain medical professionals or specialists.
- Be aware of what services are covered by your insurance plan. Some health related services may not be covered, may not be covered at 100% or have other limitations. You can always call your insurance company to check your coverage.
- Understand your plan’s coverage of special equipment, medical devices or supplies and how to order them. Your insurance may require you to use approved providers.
- When at the pharmacy, your healthcare plan may allow you the choice of whether your medication is a brand name or a generic name. Many plans offer a customized formulary which can outline the difference in cost.
No Health Insurance?
- Federally-funded health centers care for you, even if you have no health insurance. Find one near you.
- Did you recently lose a job that provided health insurance? You may have options - learn more.
