Health insurance is important to have, but it's not always easy to understand. You may have to take a few steps to make sure your insurance will pay for your health care bills. There are also a lot of key words and phrases to keep straight in your head. Here's some basic info you need to know:
What is insurance?
Health insurance helps pay for your health care. It can help cover services ranging from routine doctor visits to major medical costs from a serious illness or injury. It also covers many preventive services to keep you healthy. You pay a monthly bill called a premium to buy your health insurance and you may have to pay a portion of the cost of your care each time you receive medical services.
How do I use my policy?
Each insurance company has different rules for using health care benefits. You should look at your plan’s benefits and limitations when you first sign up for insurance, especially if the plan requires you to receive your care from certain doctors and hospitals, as most plans do. In general, you will give your insurance information to your doctor or hospital when you go for care. The doctor or hospital will bill your insurance company for the services you get.
What do I use an insurance card for?
Your insurance card proves that you have health insurance. It contains information that your doctor or hospital will use to get paid by your insurance company. Doctors usually make a copy of your insurance card the first time they see you as a patient.
Your card is also handy when you have questions about your health coverage. There's a phone number on it you can call for information. It might also list basics about your health plan and your co-pay for office visits.
What's a network?
Doctors and hospitals often contract with insurance companies to become part of the company's "network." The contracts spell out what they will be paid for the care they provide. If you go to a doctor in your insurance company's network, you will pay less out of your own pocket than if you go to a doctor who doesn't have a contract with your insurer. Some insurance plans will not pay anything if you do not use a network provider (except in the case of an emergency). So it is important to consult the plan’s network before seeking care.
How do I find a doctor or hospital?
You can call your insurance company using the number on your insurance card. The company will tell you the doctors and hospitals in your area that are part of their network. You can also find this information on the insurance company's website.
Everybody with health insurance should have a doctor who will oversee their medical care. That means you will need to find a doctor -- also called your primary care physician -- who is taking on new patients. If you have young children, you will need to find a pediatrician or family practice physician for their care. Calling doctors on the list of your insurance company allows you to confirm they are still in the plan's network. Once you've found a doctor who will take you as a patient, set an appointment for your first checkup.
What do I do when someone is sick?
If you or a family member gets sick but it's not an emergency, call your family doctor or pediatrician and make an appointment. If your doctor can't fit you in, you might go to an urgent care center. These centers can treat some serious injuries and illnesses. For instance, you can go there to get stitches for a bad cut or to be checked if you have a high fever. Call your insurance company first to make sure it will pay for treatment there. Your insurance may also cover care at a retail-based clinic like the ones at large stores with pharmacies. They are usually staffed by nurse practitioners but cannot treat serious illnesses or injuries. If you need to be tested for strep throat or need a flu vaccine and can’t get an appointment with your regular doctor, an in-store clinic is another choice. Before going to a walk-in clinic, check with your insurance company to make sure they will pay for any care you receive there.
If you have a life-threatening medical emergency, go to the hospital emergency room. For instance, if you're having a heart attack or are bleeding badly from a wound, call 911 or go to the ER. You can always get treatment at an emergency room, no matter what type of insurance you have -- but it may cost you more than if you went to a doctor’s office or an urgent care clinic for treatment. If possible, call your insurance company before you go to an emergency room.
How much do I pay?
Paying for health care involves two types of costs. You pay a monthly premium and your cost-sharing -- the portion of each treatment or service that is your responsibility.
The amount of money you pay varies from plan to plan.
How much does the insurance company pay?
Most health plans have a dollar amount called the deductible. That's the amount of money you have to pay before your insurance will pay anything. For instance, you might have to pay $1,000 in medical bills before your insurance kicks in. Plans may cover some services without requiring you to reach the deductible, such as a certain number of sick visits and well visits.
Once you’ve met your deductible, the insurance company will begin to share in the cost of your medical bills. In addition to the deductibles, you typically will have to make a copayment or pay coinsurance:
- Copayments, or copays for short, are fixed amounts you pay for covered services. For instance, you might have a $10 copay every time you see your primary care doctor or $30 every time you see a specialist. This amount stays the same no matter how much the visit costs.
- Coinsurance is the percentage of the cost that you're responsible for. Say your coinsurance is 20%. For a medical service that costs $400, you'll have to pay $80. The insurance company pays the rest.
What about preventive care?
Most health plans are required to cover preventive care without any cost-sharing. This means even if you haven’t met your annual deductible, you can still receive preventive care services for free. Preventive care benefits include immunizations, some cancer screenings, cholesterol screening, and counseling to improve your diet or stop smoking. You may be required to receive preventive care from a doctor in your plan's network. You can find a list of all the free preventive care services here. Some plans that existed prior to 2010 that have not substantially changed -- known as grandfathered plans -- and short-term health plans – those that provide coverage for less than a year -- do not have to provide free preventive services. Check with your insurance company or HR department to find out if your plan is grandfathered.
What if I need a specialist, like a heart doctor?
Some health insurance plans require that you get a referral from your family doctor to see a specialist. Call your insurance company and ask. If that's the case, your doctor will give you a referral to the specialist you need. The specialist may need the referral paperwork prior to seeing you in the office, so make sure all the paperwork is completed. Check to see if the specialist is in your insurance company's network. If they aren't, you might have to pay a bigger part of the bill or perhaps the whole bill. You can ask your family doctor to refer you to another specialist in your plan’s network.
How do I get prescriptions?
The Affordable Care Act requires that all health plans sold to individuals or through small employers cover prescription medications (short-term health plans are not required to offer this coverage). Although not required, prescription drug coverage is almost universal among large employers. Check with your insurance company to see if they require you to use a pharmacy in their network. Pick a pharmacy close to where you live, and let your doctor or hospital know its name and phone number. Your medical team usually will call the pharmacy directly about the prescription you need. Otherwise, your doctor might give you a written prescription to take to the pharmacy.
At the pharmacy, give your insurance card to the pharmacist so they'll know how to bill your insurance company. Depending on your plan, you might have a separate card for prescriptions. You'll usually have to pay part of the bill for your medicines. Keep in mind that you'll usually pay less for generic drugs than for brand-name drugs. If it is a long-term medication, you may want to fill a 3-month prescription at once; it is typically cheaper that way than getting monthly refills.
Your insurance company has a list of the drugs that it covers. This list is called a formulary. You can find it online or call your insurance company to make sure the drugs prescribed by your doctor are covered. If they aren't, talk to your doctor about similar drugs you could take.