If your plan has one or more of these, here is what it means for you:

Copayment (or copay)
This is the amount you will pay to a provider (your doctor or hospital) at the time of service. For an office visit, copays are typically between $5–$50. Keep in mind that money spent on copays will not count towards your deductible.

Deductible
This is the total amount you will pay for covered services (such as nonpreventive office visits, lab tests, and other items) before your health plan pays some or all of the bill. Only covered services count towards the deductible.

For example, if your plan has a $1,000 deductible, you will pay the first thousand dollars of bills from your provider (your doctor, lab, or hospital). After you reach your deductible, you will not have to pay any more money for most covered services for the rest of your plan year. Your health plan will pay those bills. You may still have to pay copays or coinsurance.

You may not have to pay for preventive care and screenings, such as check-ups and mammograms. Check your Evidence of Coverage or Benefit Document to see what your health plan pays for and what counts toward your deductible.

Coinsurance
This means you will be sharing the responsibility of paying for a service (like an office visit, procedure, or admission) with your health plan. Usually coinsurance is listed as a percentage.

For example, say your plan has 20% coinsurance and your doctor charges $100 to perform a procedure. You would pay $20 to the doctor and your plan would pay the other $80. Sometimes coinsurance only applies after you have met your deductible.

Related posts:

1. Your Health Insurance Checklist
2. Choosing a Health Plan
3. What Kind of Health Plan Do You Have, and Is It the Right One for You?

Knowing What Drugs Are Covered

Where to begin? It all starts with the list of drugs your health plan covers. This is commonly called a formulary.  Both generic and name-brand drugs will appear on this drug list. Only medications on the formulary will be covered by your health plan.

Many health plans will place drugs on different levels (or tiers) based on how much the drug costs. There can often be three or more tiers on the drug list/formulary.

• Tier 1 — Has the lowest copayment. Includes the least expensive brand-name drugs and most generic drugs.
• Tier 2 — Mid-level copayment. Often includes brand-name drugs that have no generic substitute.
• Tier 3 and up — Highest level copayments. Includes the most costly brand-name drugs that your health plan covers.

Why is this important to know? Say your doctor prescribes you a brand-name drug. It is possible that this drug may have a generic substitute or a cheaper alternative. You can always ask if there is a drug on a lower tier level that is equally beneficial to you.

Remember to check your health plan’s formulary whenever you get a new prescription. As new drugs become available, health plans update their lists and may move a prescription to a new tier.

Generic Vs. Brand Name

If generic drugs are cheaper, is there a catch?  Not at all! Generics have the same active ingredients and come in the same strengths and dosages as brand-name drugs.

Prescriptions By Mail

Do you take any prescription drugs regularly? If so, you may be able to save money by ordering these “maintenance medications” through the mail. Many health plans offer discounts for ordering through the mail.

Usually, you order a 90-day supply but only pay the copayment for a 60-day supply. It’s like getting a month free! Not only is it cheaper, but it is more convenient too. You don’t even have to visit the pharmacy.

This mail-order discount works best if your medication does not have any dispensing limitations, meaning you can only get a limited amount of the medication at one time.

Talk With Your Doctor And Pharmacist

By knowing your prescription drug benefits and discussing your medications with your doctor and pharmacist, you can be sure that you are getting the drugs you need at the best price. That should really make you feel good.

Related posts:

1. The Top 10 Things You Should Know About Your Health Plan
2. Your Health Insurance Checklist
3. Choosing a Health Plan

Certain types of plans require you to have a PCP, like HMOs, but others do not. Whether it’s required or not, it is a good idea to choose one. Having one provider coordinate your care means that at least one person sees the whole picture when it comes to your health.

How to Find a Primary Care Provider (PCP)
If you already have a PCP, just call their office and confirm that they accept your new insurance. Then register your PCP with your new health plan. You can usually do this online or by calling the number on your health plan ID card.

If you need to choose a new PCP, ask yourself if you want to see a doctor or nurse practitioner close to home or to your office. Your health plan’s online search tool or member services department can help you find providers near you.

If you are not sure which PCP to pick, make a list of PCPs you may want to use. You can narrow your list down by providers’ quality and satisfaction ratings. Most plans have this information available online, or you can find ratings from NCQA (National Committee for Quality Assurance) and MHQP (Massachusetts Health Quality Partners). Confirm with the doctor or nurse practitioner that they accept your insurance.

Become a Patient
Now that you know who you want as your PCP, contact their office and ask if they are taking new patients. If they say no, consider asking if anyone else in the practice is accepting new patients. Or call the next PCP on your list until you find one that is accepting new patients.

Once you’ve settled on a PCP choice, make an appointment for a routine checkup right away. These types of appointments can sometimes have longer waits, and it will be much easier to make a sick appointment after you are an established patient. Finally, be sure to let your health plan know you’ve selected a PCP.

Related posts:

1. What Kind of Health Plan Do You Have, and Is It the Right One for You?
2. Choosing a Health Plan
3. The Top 10 Things You Should Know About Your Health Plan

While everything your health plan sends you is important, there are some letters you should pay closer attention to. Anything that requires you to do something (like paying a bill) should be clearly marked as such. Here’s a field guide to what you can expect:

Evidence of Coverage (EOC)
This is the thick packet you get after joining a new plan. The Evidence of Coverage or Benefit Document details everything that is and may not be covered in your plan. It is a good idea to read it — and file it with your important paperwork. You’ll want to have this on hand if you have questions about your plan later.

Benefit Updates
When changes have been made to your coverage (a health service your health plan will pay for), you will be mailed an update letter that describes those changes. File this with your Evidence of Coverage.

Explanation of Benefits (EOB)
This is the document that may look like a bill even though it says, “This is not a bill.” Most health plans are required to send an Explanation of Benefits letter after a claim is processed.

The EOB breaks down:

• what kind of care you received,
• how much the provider billed,
• how much money your health plan gave toward payment, and
• any remaining balance.

If there is a balance, you may be sent a bill from your provider (your doctor, lab, or hospital).

Bills
All bills for your health care services will come from your health care providers (your doctor, lab, or hospital). Payments for services are due to them, not your health plan.

Statements
If your plan has a health reimbursement arrangement (HRA) or a health savings account (HSA), you will receive periodic statements. Similar to a bank statement, these will show the activity and balance of your account.

Related posts:

1. Making Sense of Copays, Deductible, and Coinsurance
2. What Kind of Health Plan Do You Have, and Is It the Right One for You?
3. The Top 10 Things You Should Know About Your Health Plan

A deductible is the amount you pay for health care services before your coverage kicks in. The concept can sound a little daunting to those of us on a budget.  But with proper planning, this can be a great option if you know your family’s needs and plan appropriately. 

With many health plans, you pay higher monthly premiums up front for your health care but pay less money when you use your benefits. With a deductible plan, you generally have lower monthly premiums in exchange for paying out of pocket for medical costs.

While you can save a lot of money on premiums with deductible health plans, you have to be prepared to pay the full cost for many doctor visits, hospitalizations, and other bills until you reach your deductible limit.

To help you save money for these expenses, deductible health plans are often linked to a health savings account, or HSA. An HSA is a bank account that you put money in — tax free — to pay for eligible health care expenses (such as doctor visits, lab tests, hospitalizations, prescription medications, and even medical equipment). With these accounts, earnings on savings are allowed to accumulate tax free and roll over year to year, as long as the money is ultimately used to pay for medical expenses.

Is a deductible health plan right for you? If you choose one, it’s very important that you educate yourself about health care costs. You may be surprised when you find out the full cost for health care services, but online resources are probably available on your health plan’s website to help you estimate potential expenses. You will need to make choices about what care to receive and where to get it while keeping cost in mind.

So you should consider how healthy you and your family are, think about what kind of health care issues you might have in the future, and decide if you’re willing to take a more active role in managing your health care and your overall health.

Related posts:

1. HRA (Health Reimbursement Arrangement)
2. What Kind of Health Plan Do You Have, and Is It the Right One for You?
3. Choosing a Health Plan

Online access to your plan information  — Many plans offer you password- protected access to information about your plan, so you can get the information you need when you need it. For example, with some health plans you can do the following:

• View benefits to see what’s covered.
• Check copayment and any coinsurance amounts.
• View your plan deductible, if any, and track how much you have accumulated towards it.
• Learn about your pharmacy coverage.
• Track prescription drug expenses, and refill prescriptions you receive by mail.
• Confirm any needed referrals or required authorizations.
• Review the status of doctor and hospital bills (often called “claims”).
• Order a replacement ID card.

Check with your health plan to see what online tools it offers, and then check out its site. You’ll be glad you did.

Member discounts — Your health plan coverage may allow you to take advantage of discounts on such things as massage therapy, eyeglasses, fitness membership fees, weight-loss programs, and running shoes.

Online health library — Need to know when your child is due for an immunization? Have questions about a symptom you just noticed? Your health plan may offer an online health library where you can research these questions and more.

Tools and calculators — Interactive gadgets are everywhere, and your health plan’s website is probably no exception. You might be able to do your own health assessment, calculate your body mass index, check on how many calories you burn while exercising, or even take a sleep quiz. Now that should help you rest easy.

Health and wellness programs — We all know that taking good care of ourselves is as important as getting the right care when we’re sick. That’s why many health plans offer a variety of programs designed to help you get and stay healthy. You might find programs to help you quit smoking, manage your asthma, or deal with stress. Interested in learning more about nutrition for you and your family? Interested in parenting classes?   You may get a discount for these types of programs, thanks to your health plan. You should be able to find all the above and much more on your plan’s website.

Related posts:

1. The Top 10 Things You Should Know About Your Health Plan
2. Your Health Plan in Your Mailbox
3. Choosing a Health Plan

Here’s a simple checklist to help you get to know your health insurance coverage better.  You can reference this list when making coverage decisions for yourself or a member of your family.  Make sure you check the specific definitions, terms, and exclusions of your coverage.

My plan type is:
❑ HMO (health maintenance organization)
An HMO is a type of health plan that provides coverage through your doctor, hospitals, specialists, and other providers on an approved list.  Usually with an HMO you will need a referral from your primary care provider for specialty care.

❑ PPO (preferred provider organization)
A PPO health plan allows you to use health care providers, even those that are not on your health plan’s approved list.  If you choose a provider who is not on the health plan’s approved list, you may pay a higher copayment or coinsurance. You do not need referrals from your primary care provider to see a specialist in a PPO plan.

❑ POS (point-of-service)
A POS health plan allows you to choose between two options.  In the first level of coverage, you may obtain care from a primary care provider (PCP) on your health plan’s list of approved providers. In this case, your PCP will coordinate the care you receive from other providers and you will be covered at the authorized level of care.  Or you may choose to receive care that is not coordinated through your PCP. With this second option, you usually pay a higher copayment or coinsurance.  You do not need referrals in a POS plan to receive coverage at the unauthorized level of care.

❑ Indemnity (sometimes called fee for service)
In an indemnity plan, you can go to any doctor, hospital, or other health care provider for covered services.  The provider may bill your insurance company directly, which pays a portion and sends you a bill for the balance.  Or you may pay the provider directly for services, then submit claims to your insurance company for reimbursement.  You do not need referrals.

❑ Not Sure ___________________________

My copayments are as follows:
-Office visits      $_____
-Specialists        $_____
-Hospital stays    $_____
-Emergency care    $_____
-Prescription drugs – You might have different levels (or tiers) of copayments.  For example, generic drugs usually have lower copays than do brand-name drugs.   $__________

I had to choose a primary care provider (PCP) when I signed up with this plan:
❑ Yes
❑ No

My PCP is _____________________________ .

I need a referral or approval from my PCP for:
❑ Specialist visits
❑ Surgeries or other procedures
❑ Mental health services

My PCP can refer me to specialists who:
❑ Are on the health plan’s list of doctors, hospitals, and other health care providers.
❑ Are NOT on the health plan’s list of doctors, hospitals, and other health care providers.
❑ I do not need a referral.

I have reviewed my coverage for services I expect to use, which may   include:
❑ Routine physical
❑ Inpatient and outpatient hospital care
❑ Laboratory services and X-rays
❑ Physical therapy
❑ Mental health
❑ Prescription drugs
❑ Other _______________________________________

I understand that my out-of-pocket maximum is $______________ (if applicable).  An out-of-pocket maximum is the most a member would need to pay for services during a plan year.

I understand that my deductible, the amount of money paid out of pocket before coverage kicks in for most services, is $______________ (if applicable to my plan).

I have reviewed the Exclusions and Limitations in my policy and understand that my health insurance coverage will not pay for or pays a limited amount for the following services:
____________________________________
____________________________________
____________________________________

Related posts:

1. Choosing a Health Plan
2. What Kind of Health Plan Do You Have, and Is It the Right One for You?
3. HMO (Health Maintenance Organization)

HMOs
HMOs (health maintenance organizations) began with the idea that your doctor should not only take care of you when you’re sick but should also work with you to prevent illness and emphasize wellness.  Generally, in an HMO health plan:

• You are required to get your care from your health plan’s list of participating doctors, hospitals, and specialists.
• You can’t use doctors and specialists who do not participate in your health plan except in an emergency or for urgent care, or if your plan says it’s okay ahead of time.
• You have to live in the area where your HMO covers services.

With an HMO health plan, you’ll have to choose a primary care provider (PCP) for yourself and everyone in your family. Each person in your family can have a different doctor, but each of your PCPs will oversee and coordinate all your care. You’ll need a referral – approval from your PCP – for services not provided at your doctor’s office or to see a specialist.

Is an HMO the right health plan for you? Some people really like having a doctor to help manage their care and want their doctor to be involved when it comes to choosing specialists for them.  In many cases, you pay a lower premium if you’re in an HMO than if you’re in another type of plan.

PPOs
Like HMOs, PPOs (preferred provider organizations) have doctors who participate with your health plan.  Two key differences are:

• You do not need referrals from a PCP to see specialists or other health professionals, and
• You have the option to see doctors who do not participate with your health plan, but your health plan will not cover as much of the costs.

Many people like this option because you don’t need to choose a PCP or need a referral to see a specialist.  It’s still a good idea to have a primary care provider, though, as someone who can help you manage your overall health.

Is a PPO health plan right for you? If you want the flexibility to see any doctor without having to get referrals, then a PPO may be a good choice. You’ll most likely pay a higher premium, the monthly cost for your health plan, but if you want to have full control over where you get your care, it could be worth it.

POSs
A POS (point-of-service) plan combines features from both HMOs and PPOs. With a POS health plan, you choose a primary care provider, or PCP, to oversee your care, and that PCP becomes your “point of service.” Your PCP will provide most of your medical care and will generally refer you to specialists who participate with your health plan. You can still see a doctor or other health care professional who doesn’t participate with your plan, but the coverage may be less or your costs may be higher.

Is a POS health plan right for you?  You’ll have a PCP to guide you, but you’ll have the flexibility to see any doctor you want for a higher cost. For many, it’s like having the best of both worlds.
Please note: All three types of plans above could have a deductible, the amount you pay for services before your coverage kicks in, so review your plan description to be sure that you are aware of all the costs.

Related posts:

1. Choosing a Health Plan
2. Your Health Insurance Checklist
3. The Right Health Insurance Plan for You

1. Is your doctor on the health plan’s list of participating doctors and hospitals? Some health plans require you to use a specific network (or list of participating doctors and hospitals) of health care providers. If you have a doctor you want to keep seeing, check to make sure he or she participates in the health insurance plan you are considering.  If you have children, don’t forget to check whether your child’s pediatrician is on the list as well.
2. Have you been seeing a specialist? If you have a medical condition that requires you to see a specialist, check to see whether he or she is on the health plan’s list of participating doctors.  Keep in mind that if your health insurance plan requires you to choose a primary care provider, you most likely will need a referral (prior approval from your primary care provider) to see a specialist.
3. What should you do if you are already being treated for a specific condition? If you are currently undergoing treatment, call your new health plan’s customer service department to let them know about any upcoming procedures and your doctors’ names. They may have a nurse case manager, who can work with you and your providers to coordinate your care and help you get the necessary authorizations for services.
4. Are emergency services covered? Do not hesitate to go to the nearest hospital in an emergency, no matter what health insurance plan you have. In most plans, emergency care is covered. However, you may have to pay a copayment or a percentage of the total cost. And find out what constitutes an “emergency.”   Sometimes your definition of an emergency may not be the same as the health plans’.
5. What kind of additional health care services are covered? When comparing health insurance plans, consider what additional services are covered and what is important to you.  Examples might include fitness and wellness programs, home health care, or chiropractic care. All these services may not be necessary for you, but you never know what may arise in the course of a year. Make sure you know what options you have before choosing a plan.
6. What does the health insurance plan exclude from coverage? You should look for and review the list of services that the health plan specifically excludes from coverage, to make sure it doesn’t include anything you currently need or think you might need in the future.
7. What is this going to cost me? If you get your health coverage through your employer, you’ll pay your share of the monthly premium (usually deducted from your paycheck), but you will likely also have copayments for office visits and prescription drugs. You might have a deductible, the amount you pay out of pocket before your coverage kicks in.  And you may have to pay for a portion of the costs if you’re hospitalized.  Keep in mind, your employer is the one who determines the health care coverage options at your company.

So how can you get an idea of what a new health insurance plan will really cost you? You may want to look back on your experience last year to estimate what you might have to pay on a new plan.  Or you can compare health coverage costs side by side among health plans. Whatever your choice, it pays to take your time before choosing your health insurance plan so you know what to expect.

Related posts:

1. What Kind of Health Plan Do You Have, and Is It the Right One for You?
2. Your Health Insurance Checklist
3. The Top 10 Things You Should Know About Your Health Plan

Related posts:

1. Choosing a Health Plan
2. What Kind of Health Plan Do You Have, and Is It the Right One for You?
3. Your Health Insurance Checklist