Health Insurance 101 teaches you the basics of how medical insurance plans work. Follow our patient and his journey through the system.

What You Need To Know

HEALTHCARE is the care you receive when you go to the doctor or the hospital.  HEALTH INSURANCE is a product that covers your medical expenses. You or your employer will pay a monthly premium to the insurance company each month to maintain your coverage.   Everyone should have health insurance coverage because:

  • Accidents and health problems can occur anytime
  • Healthcare is expensive
  • Health insurance provides access to a network of doctors and hospitals that have negotiated a lower rate with insurance companies
  • Insurance pays for preventive care like annual doctor visits and tests before you get sick.

Unless it’s an emergency, you may want to ask yourself the following questions before seeking treatment, and if you are unsure of the answer, the best course of action is to call your health insurance company or check your plan document:

  • Do you need to stay within a provider network to get the lowest cost?
  • Will your services be covered under your plan?
  • Are you seeking the right kind of care at the proper facility? (telemedicine, walk-in clinic, primary care clinic, urgent care, etc.)

When you go to the doctor, remember to bring your insurance card.  It contains important information such as:

  • Your name
  • The name of your insurance carrier
  • Your member ID number
  • Your group ID number
  • If you owe a co-pay at the time of service
  • Which type of insurance you have
  • Where to submit your medical bill

Once the Insurance Company receives the medical bill, they will do the following:

  • Verify that you are an eligible employee or dependent on the plan
  • Verify that the medical charges are a covered expense and not a medical exclusion
  • Verify that you went to an in-network provider
  • Discount your claim because you stayed in-network rather than going to anout-of-network provider
  • Pay their portion of the bill based upon where you are with your deductibleco-insuranceco-payor out-of-pocket charges
  • Send an EOB (Explanation of Benefits) to you in the mail or via email. It will explain the charges, tell you the discounted rate, tell you what they have paid, and tell you how much of those charges are your responsibility to pay

After this process, it will be up to you to do the following:

  • Compare your EOB (Explanation of Benefits) to the bill you have received or will be receiving from your doctor. Make sure that the money you owe is the same on both statements. If it is NOT the same, you should contact your insurance carrier or your medical provider to find out why
  • Make sure that you received all the services that you are being billed for
  • You have the right to dispute your bill if you believe that you are being overcharged or if you are not paying the usual and customary rate
  • You have the right to ask for an additional discount from your provider before you pay your bill
  • You may pay your bill outright, or check to see if you have an HSAHRA or FSA plan that you can draw from
  • Pay your bill before the grace period runs out

*Make sure you set up your personal account on your insurance carrier’s website.  This is where you can review your benefits, claims, and what is left on your deductible, co-insurance and out-of-pocket costs for the year.  You can also access the Disease Management team, Nurse Line, and many other valuable programs.

Always remember, if you have questions regarding an issue with your medical insurance plan, call your insurance carrier.  They are there to help!

What You Need To Do

1. If you are unsure of your coverage, you should call your insurance carrier or check your plan doc.
2. Make sure you are seeking the appropriate care. (telemedicine, walk-in clinic, primary clinic, urgent care, etc.)
3. Check your provider network to make sure that it includes your doctor and treatment facility.
4. Bring your insurance card with you to the doctor’s office.
5. After the insurance company sends you an EOB, compare it to your bill from your provider to ensure they are the same.
6. Check your bill to make sure you received the services that you are being billed for.
7. If you feel that you are not being billed fairly, you can dispute the charge or ask for a lower rate.
8. Pay your bill outright, or use your HSA, HRA or FSA plan if applicable.