Review all materials about your health coverage and ask questions if anything is unclear.
Know which insurance company is providing your health insurance, not just the marketing name that may have been used in advertising.
Check that the company is licensed and registered as an insurance company in Colorado using the Division of Insurance’s website.
What is the premium you will pay for coverage? How often do you have to pay?
The premium is the amount you pay for health insurance to the health insurance carrier. Although it is often a monthly premium, there may be other payment options, such as paying for several months or a year’s coverage in advance.
Know what the health insurance covers and does not cover.
Are there items, services the insurance will not pay for (known as exclusions and limitations)? Are there certain situations where it will not pay for all of your medical care?
For example, experimental procedures, alternative health treatments, hearing and vision aids (such as eyeglasses and contacts), and dental treatment are common exceptions or limitations. Find out how visits to the doctor’s office, regular checkups, visits related to illness or a specific condition, lab work and tests, and emergency care are covered.
Under Federal healthcare reform (the Affordable Health Care Act), starting in 2014, insurers cannot deny coverage due to a person’s pre-existing condition. Also, they can no longer set lifetime limits on benefits.
Find out about any special rules, such as referrals or pre-approval for procedures, that may affect how the insurance pays for coverage.
Your insurance may require written notice before you get certain lab tests, see a specialist or have a medical procedure done, especially if any of these services use a doctor or provider outside of the insurance carrier’s network.
Does the insurance plan offer coverage if out-of-network doctors and providers are used? If so, are the payments different for in-network and out-of-network providers, including deductibles, co-payments and co-insurance?
While many plans offer coverage when out-of-network doctors and providers are used, some do not, except for emergency care. Those that do offer out-of-network coverage often have different co-pays, co-insurance and deductible amounts for out-of-network services.
What is the deductible amount and what time period does the deductible cover? Is the deductible for each covered person on your policy or for the entire family?
The deductible refers to the amount of money that the insured or covered person would need to pay before the health insurance pays for most services and procedures. If your deductible is $1,000, then you will be responsible for the first $1,000 in expenses. When you have paid $1,000 out of your own pocket, then the insurance begins to pay its share of the covered expenses.
Generally, the higher the deductible amount, the lower the premium. If you have a high deductible, for example, $10,000 in a year’s time, then you must pay that amount out in medical expenses yourself, before the insurance will contribute to paying for your healthcare. If you select a high deductible plan, you should also have the resources to pay that deductible amount when necessary.
Some deductibles cover a calendar year, some are plan year, some are July 1 to June 30, and some deductibles are 12 months from the policy’s effective date. Some health insurance policies have a deductible amount per occurrence. At the end of the deductible period the amount usually goes back to zero, and you will begin to pay for services again.
Health insurance can specify deductible amounts for each person covered, or may have the option of a “family” deductible that can be satisfied by the total amount of covered medical expenses paid by a family. Be sure you know what your deductible amounts are when you are selecting health coverage.
Remember that under Federal healthcare reform, starting in 2014, many preventive services are paid by the health insurance without having to pay the deductible amount.
Will the health insurance cover 100% of costs after you have reached the deductible amount, or must you pay a percentage of costs (known as co-insurance) after you have met the deductible? How much is this percentage?
Some health insurance plans require the insured or covered person to share the costs of medical services, even after the deductible has been paid. For example, a plan may state that after you have paid the deductible amount, the plan will pay 80% of covered medical expenses, and you would be responsible for the other 20%. Some policies pay 100% after you have met the deductible amount.
Is there a “cap” or limit on any of the health insurance benefits? Are there limitations on total expenditure per procedure or treatment?
For example, some policies may only pay for a certain number of physical therapy visits per year. Be sure you understand the amount of any cap on the policy.
Beginning in 2014, under Federal healthcare reform, insurers can no longer set yearly or lifetime limits on benefits.
Is there a co-pay amount for doctor visits or treatment?
A co-payment or “co-pay” is the amount the insured or covered person pays for each visit to a health provider (such as a doctor or physician’s assistant or lab) or for prescription medication. The health insurance should state what these co-payments are up front. The co-payment is a way of sharing expenses with the health insurance carrier.
The co-pay may be a set amount (such as $25 or $35 per doctor visit) or may be a percentage of the covered charge. There may be a different co-payment expected for special services such as an emergency room visit.
Usually, the co-pay amount is paid at the doctor’s office, lab, medical facility or pharmacy at the time of the visit and it is rarely billed by the provider.
Do I have to pay an access fee for services? What is an access fee?
Generally, an “access fee” is an amount that the individual doctor may charge the patient for services NOT covered or reimbursed by insurance. The types of charges might include consultations by email, phone and fax; consultation fees on weekends or after office hours; handling prescription refills; providing or copying medical records; helping a patient appeal a health insurance carrier denial of benefits; or arranging for medical equipment. Find out from your doctor or medical facility if there are charges you might incur that are not covered by insurance. Your health insurance should state whether or not “access fees” will be covered.
Understand how the health insurance may be renewed or cancelled (by you or the insurance company).
When you are shopping for new health insurance, be sure you understand renewal, cancellation and termination provisions. Many types of individual insurance policies are guaranteed renewable as long as you continue to pay the premium. However, you should always find out if you need to do anything each year to renew the policy, or if it will be renewed automatically.
The insurance should also state if the carrier can cancel your health insurance, and if so, how much notice must be given to you, and how this notice will be delivered to you. If you decide to cancel your health insurance (for example, if you get other coverage, or find a different policy that you prefer), how much notice must you give to the carrier, and how and when that notice must be delivered to the carrier.
What specific steps to take if you are denied a benefit or coverage to which you believe you are entitled under the policy?
Your health policy may specify that you need to get approval before seeing a specialist or scheduling certain procedures. Be sure you understand your responsibility in this process and allow enough time for referrals and approvals when required.