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Using Your Health Insurance

Your Health Insurance Card

When you sign up for health insurance, you will receive a health insurance card in the mail from your health insurance provider. Your insurance card proves that you have health insurance, so make sure to bring it with you whenever you go to see a healthcare provider.

Click the green plus signs on the images below to learn about the different kinds of information on your health insurance card.

Member Handbook

When you sign up for health insurance, you will also receive a Member Handbook, either in the mail or online. It contains a lot of valuable information, so keep it handy. It details what benefits are covered, and how much they will cost. 

The handbook also provides information on the health plan’s preferred network of providers, meaning where they prefer you go to get services, including primary care, specialty care, mental health and substance abuse treatment, and urgent care. You can get care outside this network, but it will usually cost more. The handbook will also include information about your health plan’s formulary, which is the list of prescription medications that your health plan will pay for, and how to contact your health insurance provider to ask questions, make claims, and appeal decisions.

Health Insurance Costs

There are many kinds of costs associated with your health insurance:

  • Premium is the amount that you pay for your health insurance every month. The amount varies depending on what kind of health insurance you have (from $0 for Medicaid to several hundred dollars for other health plans). If you have an employer-sponsored health plan, this amount is usually deducted from your paycheck.
  • Deductible is the amount that you must pay for healthcare services you receive before your health insurance will start to pay. After that, your health insurance will cover all of the costs of your care, except for copayments and coinsurance (see below). For example, if your plan has a $1000 deductible, that means you must pay the first $1000 of your healthcare costs within a given year. This is called “meeting your deductible.” Some healthcare services, such as checkups, will be covered by your health plan before you meet your deductible.
  • Copayment (copay) is a flat amount that you pay for a particular health service. Usually you will pay the co-payment at the pharmacy or doctor’s office when you go. For example, you might be asked to pay $20 for a doctor’s visit or a prescription.
  • Coinsurance is the percentage of the total cost of a healthcare service that you must pay after you have met your deductible. Usually you will receive a bill for this amount from your healthcare provider in the weeks after you receive the care. For example, if your coinsurance is 20 percent, that means you pay 20 percent of your healthcare costs and your health plan pays for the rest. If you get care outside of your health plan’s preferred network of providers, you will usually have to pay a larger percentage of the cost.
  • Out-of-pocket maximum: This is the maximum amount that you have to pay for your healthcare costs in a year, not counting premiums. If you reach the maximum before the end of the year, your health plan will cover all the costs of your care for the rest of the year.

Types of Health Insurance Plan

There are four common types of health plan that differ by flexibility in choosing your healthcare providers and facilities:

Health Maintenance Organization (HMO): With this type of plan, you are usually required to use only healthcare providers and facilities that are within the plan’s network. If you choose to go outside the network for care, HMOs will pay little or none of the cost. Generally, your care will be coordinated by a primary care provider (PCP) and you will need a referral from your PCP for any specialty care or tests.

Preferred Provider Organization (PPO): This type of plan will also have a preferred network of healthcare providers and facilities. However, a PPO will cover care that you receive outside the network, though it will pay less of the cost than if you had stayed inside the network (requiring you to pay more). With a PPO, you do not need a referral for specialty care or tests.

Exclusive Provider Organization (EPO): This type of plan is like an HMO (only in-network care is covered) but you do not need a referral from a PCP to see a provider in the network.

Point of Service Plan (POS): This type of plan is like a PPO (out-of-network care covered, but more expensive) but you need a referral from your PCP for specialty care.

How to Use your Health Insurance

When you want to see a healthcare provider, choose one from your health plan’s network. You can find one by calling the contact number on the back of your health insurance card or viewing a list of providers on the health plan’s website or in the Member Handbook. If you have a healthcare provider that you would like to see, you can call and ask if they accept your health insurance. Before you visit the provider, call and confirm they are a part of your health plan’s network.

When you visit a healthcare provider, they will bill your health insurance plan for your care. You may have to pay a copayment or coinsurance. You can call the phone number on the back of your health insurance card to find out what you will have to pay for a particular service or find it on your health insurance provider’s website or in the Member Handbook. 

In the weeks after you visit a healthcare provider, you will receive one or more Explanation of Benefits (EOB) statements in the mail from your health insurance company. This shows how much your care cost, how much the health insurance covered, and how much you owe. An EOB is not a bill, so you don’t have to pay anything yet. Look for the words “Explanation of benefits” and “This is not a bill” to be sure. It’s still a good idea to save these statements in case there is any confusion. You may receive more than one of these statements for a particular service. It sometimes takes health insurance and healthcare providers a little while to sort out their finances.

If you owe any money for your care, you will receive a separate bill from the healthcare provider. You will know that it is a bill because it will have an Amount Due and a deadline to pay it.

Click the purple plus signs on the image below to learn more about the different kinds of information on your Explanation of Benefits statements.

Unexpected Medical Bills

The most important thing is: Don’t ignore a medical bill. Even if you don’t think you should have to pay a bill, ignoring it may cause you to owe a lot of money and create more challenges ahead.

If you are not sure why you received the bill, call the provider’s office and ask for an explanation. Ask them to check that your health insurance has paid their share of the cost.

If your health insurance has not paid what you think they should pay, call the number on the back of your health insurance card and ask to speak to someone about an unexpected bill.

If your health insurance provider won’t pay for the medical care you received, you have a right to appeal the decision. See our page on Help with Medical Bills for more information about appealing a coverage decision.

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