Need to Knows of Health Insurance

Buying insurance

When you are looking to buy insurance you will need to decide what kind of coverage you need and how much you can afford.

Think about how often you might visit a doctor or need prescription drugs. If you have a chronic condition like diabetes and asthma, you might use your health insurance coverage more often. If you expect you would only visit a doctor for regular checkups, you might want to consider a lower cost plan.

Of course, it is hard to predict how often you might need to use your insurance, but thinking about it can help you decide what kind of coverage you need.

You will need to find out the costs of premiums, copays, deductibles, coinsurance, and the out-of-pocket limit.

Questions to ask

• How much will I have to pay for:
  • Primary care?
  • Specialists?
  • Mental/behavioral health?
• What providers are in my network? If you already have a provider, check to see if they are in network.
• How much will I have to pay for an out-of-network provider?
• When do I need a referral to see a specialist?
• How much will prescriptions cost? Check the formulary.
• What is my yearly deductible?

Understanding your insurance card and summary of benefits

After you enroll in a health plan, you will receive a membership package with your insurance card and a summary of benefits and coverage.

Make sure you understand the information about your coverage. If you need help understanding the information, call your health plan ask them to explain it to you.

Your insurance card is your proof of insurance and might look similar to the example below.

Insurance Company Name

Member name: This usually lists who purchased the insurance or the individual covered under the policy.

Member number: This number is used to identify you so your provider knows how to bill your health plan. If your spouse or children are also on your coverage, your numbers may look very similar.

Group number: This number is used to track the specific benefits of your plan. It’s also used to identify you so your provider knows how to bill your insurance.

Plan type: your card might have a label like HMO, PPO, Open, or another word to describe the type of plan you have. These tell you what type of network your plan has and which providers you can see who are “in-network” for you.

Copay: These are the amounts that you will owe when you get health care.

Prescription copayment: These are the amounts that you will owe for each prescription you have filled.

Here are some examples of how your health plan might use the terms discussed in this section to cover your medical care.

Summary of benefits

• All health plans must provide you with a Summary of Benefits and Coverage, which will have these examples showing how the plan might help pay for services.
• The actual costs and care will vary by your health care needs and your coverage

Using your health care benefits

Although you can get health care many different places, including the emergency department, it’s best for you to get routine care and recommended preventive services from a primary care provider.

You can find primary care providers in offices, clinics, and health centers nationwide. Depending on your coverage and personal circumstances, you might find a primary care provider in:

• Private medical groups and practices
• Ambulatory care centers and outpatient clinics
• Federally Qualified Health Centers
• Community clinics and free clinics
• School-based health centers
• Urban Indian clinics and tribal health centers
• Veterans Affairs medical centers and outpatient clinics.

A primary care provider will help manage your overall health and is the starting point for your using the health care system. Your primary care provider will determine if you need to be treated by a specialist for a specific condition. Types of specialists include cardiologists, gastroenterologists, orthopedists, and oncologists.

To see a specialist, you may need a referral from your primary care provider for your health plan to cover the costs of the visit. Check with your health plan before your appointment with a specialist to determine if a referral is necessary. 

Finding a primary care provider 

Check with your health plan to find providers that are in your network. Remember that you will have to pay more to see a provider that is out-of-network.

Call the Member Services number on your insurance card for a list of providers or to check if a particular provider is in your network. You can also go to your health plan’s website and search for providers.

There are several things that you might want to take into consideration when choosing a provider, including:

• Is the provider accepting new patients, or patients with your health coverage?
• Is the office close to your home or your work? How would you get there?
• Which hospital(s) does the provider work with and can you get there?
• Will the appointment times work with your schedule?
• Does the provider speak your language or have an interpreter available?

Making an appointment

When you are ready to make an appointment with a provider call, be ready to tell them:

• Your name and insurance information (be sure to tell them that you are a new patient)
• Why you want to see the provider. You might want to tell them you are looking to find a new primary care provider and ask for a “yearly exam,” or a “wellness visit,” or you might ask to come in because you have a specific concern, like the flu, allergies, or depression.
• If you have a specific need—like translation or accessible medical equipment—ask whether the provider and the office can meet that need. If they cannot, ask if there’s another provider in the office

You should also ask:

• If they can send you any forms you need to fill out before you arrive. This will save you time on the day of your visit.
• If you need to bring anything to the visit, like medical records or current medications.
• What to do if you need to change or cancel your appointment. Some offices charge a fee for missed appointments, late appointments, or appointments canceled less than 24 hours before they start.

When you get to your provider’s office, check in with the front office staff. You may be asked to provide the following:

• Insurance card or other documentation.
• Photo identification (e.g., driver’s license, government or school ID, passport, etc.).
• Completed forms.
• Your copay, if you have one. Ask for a receipt for your records.

Source: Centers for Medicare & Medicaid Services