Health Insurance 101


Health insurance can be confusing, even for medical professionals! New research shows that more than 40% of shoppers found the information difficult to understand. That’s why we are here to answer patients’ most frequently asked health insurance questions.

  1. What Type of Insurance Plan Do I Have?

First, find out if you have an Indemnity health plan or a managed care system. Indemnity health care plans are fee-for-service plans designed so that you pay a percentage the medical cost and your insurance company would pay the remaining percentage.
Managed care plans are either an HMO, where your employer pays a monthly fee for health care services, or a preferred provider organization (PPO) where you or your employer gets a discount if you use physicians under the plan. You can pick any doctor you want but you will pay more if they aren’t part of your plan.

2. How Much Will I Have to Pay for Medical Care?
First you need to find out the amount of your premium. Some policies charge a co-pay, which is a small fee for an appointment or service, usually around $10 which pay at your visit.

Some plans may have a deductible, which is the amount you have to pay before the insurance starts covering your bills. Just call your insurance company to find out what percentage you’ll be responsible for once you’ve met your deductible which will help you find out what you’ll owe.

3. What’s a network?
A network encompasses all the doctors or hospitals that your insurance company works with. If a doctor wants to be a part of an insurance company’s network, they will contract with them and agree on what will be paid for the care they provide patients. If your doctor is in your insurance company’s network, you will pay less out of pocket than to a doctor out-of-network.

4. How do I find a doctor or hospital in my network?
If you have a plan through your employer, your HR department should give you a list of providers in your network. You can also find this information by logging into your health insurance website with your account information. Staying in-network and going to those physicians or hospitals will save you money. You can also call around to different hospitals or doctors in your area and ask if they accept your insurance, but we know how annoying that can become!

Read More: Do Even the “Young and Invincible” Need Insurance?

5. What if care or supplies aren’t covered?

For whatever reason, if your insurance doesn’t cover the services or products you need, then you will be responsible for paying the total bill. Some of these costs could include:

  • Over-the-counter prescriptions
  • Chiropractic appointments
  • Acupuncture services
  • Vitamins and/or supplements

It’s important to do research about the costs certain prescriptions or medical procedures you might need in case they aren’t covered by your insurance. If not covered, you can incur more costs that you anticipated.

6. Does my insurance cover pre-existing conditions?  
All of the marketplace plans cover pre-existing medical conditions. These plans cannot reject any patients, charge more for the conditions or refuse to pay based on conditions patients had prior to coverage. Grandfathered plans aren’t required to cover pre-existing conditions though. Patients can switch to a Marketplace plan outside Open Enrollment when their original plan ends, and they can quality for a Special Enrollment Period.

7. Is there an annual out- of- pocket maximum?
An out-of-pocket maximum is the most you’ll be responsible for paying for your medical expenses during your policy period which usually spans a year. Once you’ve reached your out-of-pocket maximum the insurance starts to pay for the full amount of your expenses. Everything you pay for in regards to healthcare goes toward your deductible including copays, which goes toward your out-of-pocket max.

8. Are all services included in the out-of-pocket maximum?
As a patient, you’ll have to decide which services you want to be covered with your plan like preventive care and maternity coverage. This is because different plans cover different services.

Read More: Understand How Year-End Deductibles Work

9. Are there higher out of pocket payments for certain types of care, such as cancer treatment? 

Even if you have medical insurance, all your costs may not be covered. The Affordable Care Act is meant to make medical insurance more affordable for patients no matter their pre-existing conditions and types of care for extreme scenarios like cancer.
10. Which services require pre-approval? 
If you go to an appointment prior to pre-approval, your insurer may not pay your claims. Most procedures outside routine primary care appointments will need pre-approvals, these include GI tests, home health, pain management, radiology and diagnostic imaging procedures, sleep studies, surgery, ambulance services, prescriptions and some medical equipment.
13. Will Your Health Insurance Cover You When You Travel?
It’s important for patients to find out if their insurance benefits are still in play when they are out of town. If your health insurance plan covers you for emergency situations, it’s likely that you’ll be covered for emergency situations out of state as well.