HOW HEALTH INSURANCE WORKS

 

I have insurance, now what?

 

Once you have insurance, you should focus on getting a primary care doctor. Preventive services include health care like screenings, checkups, and patient counseling that are used to prevent illnesses, disease, and other health problems or to detect illness at an early stage when treatment is likely to work best. Getting recommended preventive services and making healthy lifestyle choices are key steps to good health and well-being.

 

 

Why should I get preventative healthcare versus emergency services?

 

  • Having a provider who knows your health needs and whom you trust and can work with, can help you:
    • Ensure you get the preventive services that are right for you
    • Make healthy lifestyle choices
    • Improve your mental and emotional well-being
    • Reach your health and wellness goals.

 

 

What/who is a provider?

 

A primary care provider is who you’ll see first for most health problems. He or she will also work with you to get your recommended screenings, keep your health records, help you manage chronic conditions, and link you to other types of providers if you need them. If you’re an adult, your primary care provider may be called a family physician or doctor, internist, general practitioner, nurse practitioner, or physician assistant. Your child or teenager’s provider may be called a pediatrician. If you’re elderly, your provider may be called a geriatrician.

 

 

Where can I find a doctor?

 

  • 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
    • Indian Health Service, Tribal, and Urban Indian Health Program facilities
    • Veterans Affairs medical centers and outpatient clinics.

 

 

 

How do I prepare for an appointment?

 

When you make your appointment, have your insurance card or other documentation handy and know what you want.

  • Here are some things you should mention when you call and what you might be asked for:
    • Your name and if you’re 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.
    • The name of your insurance provider and plan or that you have Medicaid or CHIP coverage ready. Make sure you have the correct information about which providers in the office are in your network.
    • The name of the provider you’d like to see. You may have to wait longer for an appointment if you request a specific provider, so they might recommend another provider in your network if you’re feeling sick and need to come in sooner.
    • 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 who can.
    • The days and times that work for you. Some offices have weekend or evening appointments.
  • 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.

 

 

Health insurance terms

 

Premium

A premium is the amount that must be paid for your health insurance or plan. You usually pay it monthly. You may pay it directly to the insurance company each or month or it might be deducted directly from your paycheck if you have insurance from your job.

 

Deductible

A deductible is the amount you owe for health care services before your health insurance begins to pay on the bill. For example, if your deductible is $1,000, your health insurance plan will not pay anything until you have paid (or been billed) for $1,000 worth of medical services. The deductible starts over each year.

 

Co-Pay

A co-payment or co-pay is an amount you may be required to pay as your share of the cost for a medical service or supply. You may have a co-pay when you visit your family doctor, a specialist, the Emergency Room or if you pick up a prescription drug. A co-pay is usually a set dollar amount rather than a percentage. For example, you may pay $25 each time you visit your family doctor. Or, you may pay $10 if you pick up a prescription. You generally pay this fee up front before you can receive the service.

 

Co-Insurance

Your share of the costs for a covered health care service calculated as a percentage. This may be in addition to co-payments and deductibles you may owe. For example, if you have a 80/20 health insurance plan (meaning the insurance company pays 80% of the bill and you pay 20% of the bill) then you would be responsible for paying part of the bill for that specific procedure or service. On an X-ray that costs $1,000, you might have to pay $200 to cover your part of the co-insurance.

 

Network

The network includes the doctors, hospitals, facilities and other providers that your health insurance company has contracted with to provide healthcare services. You should check with your insurance company or your doctor to make sure they are “in-network.” These providers may also be called “preferred-providers” or “participating providers.” If a provider is “out-of-network” then it could cost you more to see them or your insurance may not pay anything at all on the bill.

 

Out-of-pocket Maximum

The most you would have to pay on your medical bills each year is your out-of-pocket maximum. After you have met that limit then your insurance plan would pay 100% of covered benefits. This limit includes deductibles, co-insurance, co-pays, or other similar charges for qualified medical expenses. The limit does not include the monthly premium you pay for non-covered medical expenses. For example, in 2014 the out-of-pocket maximum was $6,350 for an individual or $12,700 for a family plan. This means that if an individual paid out $6,350 in medical bills over the course of the year then medical bills after than would be 100% covered by the insurance company for the rest of the year.

 

Explanation of Benefits (or EOB)

A summary of healthcare charges that your health insurance company sends you after you see a doctor, hospital, or provider is your EOB. It is not a bill. It is a record of the healthcare you or your family received and the summary of the bill that the healthcare provider is charging. The EOB will also summarize how much your health insurance company paid. If you have to pay, your provider will send you a separate bill.

 

 

 

WV's Health Insurance Helpline

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