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

2. 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.

3. 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.

4. 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.

5. 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.

6. 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.

7. 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.

8. 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.

9. 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.

10. 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?

11. 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?

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

13. 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.

14. Online Directory Examples

15. Online Directory Examples

16. 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.

17. 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.

18. “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”

19. 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

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

21. For more information, contact:
Jordan Rickabaugh
Navigator Project Coordinator