It’s always best to be an educated consumer, no matter what you are buying. That’s especially true when it comes to your health. And while it’s easy to leave the details to your doctor or your health plan , you have a responsibility to understand your health insurance coverage and to make informed decisions about your care. You may be faced with choices about what type of care to receive or where to receive it. Those choices can affect not only your health and well-being but also your budget, so it pays to plan ahead, as much as possible, and to be a smart health care consumer.
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:
____________________________________
____________________________________
____________________________________