Today’s health insurance comes in a dizzying array of plan types from traditional fee-for-service to managed care plan. These plans usually have one or more of the following requirements:
- Deductible – Requires consumers to pay a set amount out-of-pocket before plan benefits begin.
- Co-pay Amounts –A flat rate that the consumer must pay for various services (such as $10 for a doctor visit or $50 for an ER visit).
- Coinsurance Percentage System –The amount the insurance company pays and the amount the consumer pays based on percentages, such as an 80/20 plan where the insurance company pays 80 percent and the consumer pays 20 percent.
Benefit plans can include more than one of the above-mentioned structures. Each health care plan also has its own set of rules that you need to understand. Here are some general tips that might help:
1. Find Out Which Doctors and Hospitals Are Part of Your Plan
Insurance companies contract with certain doctors and hospitals to negotiate the amounts paid for certain services. Your plan may refer to this as being “in network.” With many insurance plans, you must use a network provider or risk paying considerably more as there is no contractual discount protection.
Before you schedule a doctor’s appointment with either a primary care provider or specialist, or have procedures performed at a hospital or outpatient facility, you should make sure these physicians and facilities are part of your insurance plan’s network. Check your insurance company’s Web site or provider booklet to help you determine what is in network for your specific plan.
2. Learn About Pre-Authorization
Your health plan may require that any non-emergency hospitalizations or surgeries be approved before you are admitted. This helps your insurance company provide the most appropriate and cost-effective care. Sometimes your physician’s office will pre-authorize a procedure when scheduling your hospital visit or surgery, but remember that it’s your responsibility to double check.
In the case of a medical emergency, your health plan may require that someone (you, a family member, your doctor or someone from the hospital) contact them within a certain timeframe for written confirmation of coverage for the hospital stay. Check your benefit plan documents on rules governing a medical emergency and what is considered a medical emergency.
3. Specialist Physicians
For many health plans today, your primary care physician (PCP) is responsible for overseeing your medical care. Your plan may require that your PCP provide you with a referral to a specialist, such as an orthopedist, cardiologist or other specialty physician. If you decide to see a specialist without a referral, your insurance plan may not pay for the visit.
Your benefit plan may have a list of covered prescription medications, which is called a drug formulary. Similar medications that are not on the list may not be covered under your plan, or you may be required to ask for generic versions of the medications. You may want to ask your doctor to make sure all prescriptions are covered by your plan.
5. Cost-Effective, Quality Service
The goal of health insurance companies is to provide quality health care services at predictable costs. Working together with your insurer can help ensure that you get the best quality at the lowest possible costs, including your own out of pocket expenses.
Insurance plans can be confusing, but you can call your insurance company for help. Your human resources department may have someone who can also help answer your questions.