Insomnia, Snoring, Sleep Apnea

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The 5 Most Important Things You Should Know About Health Insurance

Posted by amykr on December 24, 2009

It is the time of year where new insurance policies will be taking effect. Many companies have made changes to these policies and it is important that you as the user of that insurance policy understand what it covers.

The fact is that even if you call the customer line anything you are told can be incorrect and they will always refer you back to the written policy, which was provided when you signed up. That written policy will give you all the information about the policy, however it very long and sometimes quite confusing. This is the list of the 5 things you should know going into the New Year.

1. Is the Plan and HMO, PPO, POS or Co-insurance? Depending on the company or your choice of policies there can be a great many issues that different policies effect. What doctor you can see, if you can see a specialist prior to visiting your primary care doctor and how much you pay for each visit is controlled by the plan you sign up for. There may also be a requirement for prior authorization by the insurance company for testing, procedures or medication depending on the plan.
2. Do you have a deductible? A deductible is basically the amount of money you need to spend out of your own pocket prior to the insurance company paying for your care. This can be anywhere from $100-$5000 depending on the plan. Now there may be exceptions to the deductible. In some plan your visit to a physician will be a set amount and will not be used toward your deductible. So if you visit the doctor and have to $25 to see him that amount of money will not necessarily be applied to your deductible.
3. Do you have a Co-payment? This amount of money is the amount you pay for anything after you have met your deductible. So if your plan pays 80% of the cost for a procedure you would be responsible for 20% of the cost. This cost would be the price the insurance company has previously negotiated with the doctor’s office, and will not be the same as the cash price. It could be more or it could be less.
4. Do you have any riders to the plan? A rider is an extension to the plan that may limit or add extra care for the individual. Some plans have a rider that eliminates payment for any medical activity that involves weight loss. Others have durable medical equipment riders or nursing home riders, which limit this or exclude this type of care from being paid.
5. Do you have a separate prescription plan? Some plans use a different company to care for prescriptions. You can have a separate deductible or co-payment with this plan. It can also limit what medications they will pay for based on a specific formulary, or list of medications. The plans can also require that long term medication be handled through the mail rather then the local pharmacy.

If you do call the customer care line to get information make sure you ask for the representative’s name and the call ID. This way you can track where you got the information if you need to argue about coverage. But if you listen carefully they will always tell you that they are not responsible for the information they gave you and that you need to consult the policy itself.

It is always important for you to understand what your insurance will and will not cover. When the final bill comes you will ultimately be responsible for any money that was not covered by the insurance company. The more informed you are the less likely you will be surprised by your final payment.

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One Response to “The 5 Most Important Things You Should Know About Health Insurance”

  1. As a medical billing advocate, I help those who have incurred high medical bills. This article is great at informing people of the basics that they need to be aware of, when purchasing health insurance. My past experience is as a customer service representative at a major insurance company. I will also advise you that you really need to understand your benefits, and need to press your insurance company to make sure your claims are processed correctly and you are not being shortchanged. For those who are lost and need help, a medical billing advocate can help.

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