Understanding and Using Your Coverage Health Insurance 101 Understanding and Using Your Coverage

Understanding Insurance Insurance companies offer a variety of insurance plans and each plan works a little differently. When shopping for insurance, it is important to understand the terms used to describe the coverage.

The Language of Insurance Deductible The amount you must pay for health care or prescriptions before your insurance begins to pay on your behalf. Example: If your deductible is $1,000, your plan won’t pay anything until you’ve met your $1,000 deductible for covered services subject to the deductible. Copayment An amount you may be required to pay as your share of the cost for a medical service or supply. Usually a set amount. Example: Your copayment for a doctor’s visit is $25. When you go for a routine visit, you will pay $25.

The Language of Insurance Coinsurance An amount, usually a percentage, that you may be required to pay as your share of the cost for services after you pay your deductible. Example: Your coinsurance charge for an ER visit is 20%, after the deductible. If the total cost for the visit is $1,000, you will owe $200. Premiums The periodic payment to an insurance company or a health care plan for health or prescription drug coverage. Note: Your premiums will not count toward your deductible or out-of-pocket maximum.

The Language of Insurance Primary Care Provider The doctor you see first for most health problems. In many plans, you must see your primary care doctor before you see any other health care provider. A primary care doctor may refer you to other health care providers. . Specialist A Specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. Specialists receive more training in their specific area of health care.

The Language of Insurance Network A group of providers that your insurance company works with most often. Insurance companies may charge more for a provider not included in their network. You can check your network by calling your company, or going online and searching the company’s directory. Formulary The list of prescription drugs that your health plan covers. Your formulary may be tiered, with each level having different copays or coinsurance charges. Example: A Generic prescription may have a $15 copay while a Specialty prescription has a $50 copay.

The Language of Insurance Out-of-Pocket Maximum The limit you will pay out-of-pocket in a year. This fixed amount includes the yearly deductible and may also include any cost sharing (copays, coinsurance, etc.) you have after the deductible. Out-of-Network A provider who doesn’t contract with your health insurer or plan to provide services to you. You will pay more to see an out-of-network provider.

The Language of Insurance Preauthorization A clearance provided by your insurance company before you can seek certain services. Sometimes called prior authorization, prior approval or precertification. The rules around preauthorization are suspended in emergency situations. Preventive Services Health care to prevent illness or detect illness at an early stage, when treatment is likely to work best. Preventive services from in-network providers are free of charge. Examples: Flu shots and screening mammograms.

Comparing Plans Whether you shop for your insurance on the Marketplace, or go to an Agent or Broker, you will find you have many options. It is important to take your time comparing plans to make sure the one you choose meets your coverage needs and your budget.

Plan Comparison Checklist Is my doctor in-network? Does the formulary include my prescriptions? What are the copays/coinsurance charges? What is the deductible? In-network: _______________ Out-of-Network: ___________ What is my premium amount? Monthly: ___________ Yearly: _____________ Is the hospital I could be transferred to in my network?

Plan Comparison Checklist Do I have a separate prescription deductible? If yes, amount: ______________ What is my out-of-pocket maximum? Amount: ________________ Are some services excluded from this amount? Are there services that require prior authorization? How do I contact the company? Customer service phone number: ____________________ Website: _________________ When are my premium payments due? What is the method to pay them?

Understanding Your Insurance Card Member Information Policy Information Coverage Details Contact Information

Understanding Your Network You will likely be charged more for seeing providers who are not in your plan network so it is crucial to understand your network when choosing and using your plan. If you have a doctor you want to continue seeing, make sure they accept your plan before you select it. Call your company’s customer service line to ask for a list of providers in your area. Go online to your insurance company’s website and search for providers near you. Find a list of providers in your insurance handbook.

Online Directory Examples

Online Directory Examples

Using Your Coverage After you have selected a plan that fits your needs, made your premium payment, and have received your card, you can start to use your coverage. If you don’t already have a primary care doctor, it is a great first step to find one in your area. Make sure you understand the proper ways to seek care for certain illnesses and conditions.

Primary Care vs. Emergency Room Primary Care Provider Emergency Room You go when you feel sick and when you are well. You go only when very sick or when you have a life-threatening condition. You typically see the same provider each time. You see the provider who is working that day. Providers check all areas of your health. Provider’s main focus is on the problem that brought you to the ER. You may have a shorter wait time, and more time with your provider. You may have a longer wait time. Provider can access your complete health record. The provider you see may or may not have access to your full health record. *Copays and coinsurance may be higher for ER or Urgent Care.

“Coverage To Care” The Centers for Medicare and Medicaid Services have recently launched a new initiative called, “Coverage to Care”, aimed at helping consumers learn how to get the most out of their coverage. Video segments Tips for finding the right provider Tips for getting the right preventive service To learn more, visit marketplace.cms.gov Search “Coverage to Care”

COVER KANSAS The process of finding the right insurance can be complex. Navigators are available across the state to assist with enrollment through the Marketplace. Navigators can… Help you create an online account with healthcare.gov Walk you through the application process Assist in plan comparison in the Marketplace To find a Navigator near you, visit… Localhelp.healthcare.gov Insureks.org/assistance

COVER KANSAS Follow @CoverKansas on Twitter Find out more about our efforts and the Navigators in your area! Follow @CoverKansas on Twitter Like Cover Kansas on Facebook

For more information, contact: Jordan Rickabaugh Navigator Project Coordinator jrickabaugh@kspca.org 785.249.2657