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Health insurance policies can be confusing. Here are some tips on how to understand your coverage.
I know I need to understand my health insurance policy, but it looks long and confusing. Do I need to read the whole thing?
It's really important to understand the basics of your coverage. Start by reading the Summary of Benefits, which should be clearly labeled in your insurance documents.
Under the Affordable Care Act, insurance companies must provide the summery of the benefits coverage written in plain language so they will be clear to the average consumer.
So first, make sure you understand the basics of what's covered and what out of pocket costs you're responsible for.
When you're not sure about something, call your health plan before you go see your doctor, and follow the insurance company's guidelines on paperwork, referrals, and authorizations so that any claims will be honored.
I'm not totally clear on the different kinds of plans - I know there are PPO's and HMOs, but I'm not sure what the difference is.
If you're part of an HMO, or Health Maintenance Organization, you'll pick a primary care physician from a network of doctors who are approved by your insurance company.
You'll get most of your care from this doctor.
If you're part of a PPO, or Preferred Provider Organization, you don't need a referral to see any doctors, including specialists.
PPO's offer more flexibility, but you may pay more out-of-pocket when you go to the doctor if you choose to see a provider who does not participate with your plan.
There are other kinds of plans too, but these are the most common.
With the ACA in effect, how much will I have to pay for my health care?
It varies, but the ACA requires insurance companies to cover many kinds of preventive care at no additional cost over and above your monthly premium,
such as various screenings and vaccinations, as well as an wellness checks. You'll still have out of pocket costs for other kinds of healthcare services.
Let's talk about premiums, deductibles, co-payments, and co-insurance.
Premiums are the monthly fees your insurance company charges for your health plan. You may be eligible for a subsidy under the ACA to help you pay this cost.
A deductible is the amount of money you pay before an insurance company will pay a claim. It could be anywhere from zero to thousands of dollars, depending on your plan.
Copayments are often called copays, and they're set amounts that you'll pay each time you visit your doctor or fill one of your prescriptions.
Co-insurance is a set percentage you'll pay for certain covered services - for example you may pay 30% and your insurer may pay 70%.
Under the Affordable Care Act, there are no more dollar caps on how much your insurer will pay for essential health benefits - meaning there is no lifetime and no limit, no matter what your treatments cost.
What else does the ACA offer for women?
When you're buying a new plan you can't be charged a higher premium than a man.
And, you can't be denied coverage for a pre-existing condition such as breast cancer or pregnancy - that goes for men too, by the way.
If you have a private plan you may be able to get mammogram and pap smears as well as as many other recommended preventive benefits with no co-pay or any other additional cost
You do need to go to a doctor inside your network to take advantage of these free services.
and for many women for the first time they be able to get maternity and newborn care through coverage in Health Insurance Market Place
What are my options if my insurance company doesn't pay me for a claim I made, and I think they're wrong?
When your insurer denies a claim, they're obligated to explain why. You have the right to both internal and external appeals and your insurer must give you written information on how to file those appeals.
Your state may have consumer office as well
You should also check to make sure the claim wasn't denied for a clerical error - that happens.
Where can I go to get more specifics on health insurance coverage and the ACA?
At the end of this video, you'll see a list of resources that you can visit online, or you can call your insurance company or visit their website to find more information.
Yes, insurance can be confusing, but if you take the time to know the basics, you'll be able to take better advantage of all the benefits.