Skip to Content

5 Things to Know About Your Health Insurance

Health insurance changes from year to year. It is important to carefully review your health plan and be familiar with these five aspects:

 

Coverage

Before you visit the doctor for anything, it is important to know what your insurance will and will not cover. Some insurance plans will pay 100% for a yearly physical while others may require a co-pay. Additionally, certain services such as mammograms will only be covered one time per year. Other services such as lab work may go towards your deductible and require out-of -pocket payment in addition to your co-pay. Your explanation of benefits (EOB) should tell you what your insurance company will cover. 

Co-pays & Deductibles

A co-pay is a cost-sharing arrangement where you pay a certain dollar amount for a certain service and then your insurance company covers the rest of the cost. The amount of the co-pay varies depending on your insurance plan and the service you receive. For instance, a co-pay to see your family doctor could be $20 while a co-pay for an emergency department visit could be $150. It is important to remember that at most family practice clinics, MercyCare clinics included, your co-pay is due at the time of your visit. 

 

To receive insurance coverage for certain services you must first pay your deductible. A deductible is the annual amount you have to pay before your insurance begins to cover certain health care expenses. Certain services may or may not apply to your deductible, so it is important to know which do to avoid any surprises down the road. 

 

Visits to your doctor's office and receiving medical services are not the only aspects of health care that involve co-pays and deductibles-prescription medications have their own set of rules. The way prescription drugs are covered varies from plan to plan. Find out how your specific plan covers prescription drugs so that you know the cost of taking certain medicines. This way you and your doctor can work together to choose the right medication for you. 

Network

Many insurance plans have "in-network" and "out-of-network" providers. An in-network provider has an agreement with your insurance company regarding reimbursement for various procedures and will generally be more cost-effective than an out-of-network provider. Your insurance company will have a complete list of in-network providers for your plan.

Claim Payment

Just because you have insurance and your provider's office has a copy of your insurance card on file does not mean your claim will automatically be paid. Some insurance plans require you to fill out a form before payment can be issued and other plans require the patient to pay upfront and be reimbursed. Find out how your insurance plan handles claim payments prior to your visit. 

 

It is also important to know if you need prior authorization or approval from your insurance company before a service is performed or a prescription drug is filled in order for the claim to be paid. If you need to submit paperwork after the service is performed, find out what the timeframe to submit the paperwork is. Some insurance plans have a 90-day window in which to submit paperwork.

Cost of Insurance Premiums

When changing insurance plans, it is important to remember that just because the premium is lower does not mean you will pay less out-of-pocket in the long run. Your yearly deductible and co-pays need to be factored into the equation as well. If you opt for a high deductible plan or health savings account, be sure to factor in the money you will need to contribute or put aside in the event you need to use your insurance. 

 

Understanding these aspects of your health insurance can help you when selecting a primary care provider or specialist to manage your health care. It can also help you make a decision if you have more than one insurance plan to choose from.