Question 1

What Is Health Insurance?

Accepted Answer

Health insurance is a legal agreement between you (or your employer, if you have insurance through work) and an insurance company. The contract states that you pay the insurance company a premium for coverage and the insurer pays for at least a portion of your qualifying medical expenses.
Health insurance has a variety of benefits. It can protect you from paying unexpected and expensive medical bills. It also covers essential health benefits, like annual physicals. Most plans also provide free preventative care, like vaccines and screenings.

Why Do I Need Health Insurance?
Health insurance: How it protects you from health and financial risks

No one plans to get sick or hurt, but most people need medical care at some point. Health insurance covers these costs and offers many other important benefits.

Health insurance covers essential health benefits critical to maintaining your health and treating illness and accidents.

Health insurance protects you from unexpected, high medical costs.

You pay less for covered in-network health care, even before you meet your deductible.

You get free preventive care, like vaccines, screenings, and some check-ups, even before you meet your deductible.

How Does Health Insurance Work? 
People with health insurance usually pay a health insurance premium for coverage. If you get coverage through an employer, the business will likely deduct your portion of the premium from your paycheck. The premium depends on a few factors, like the plan type and your location.

Before you visit a doctor, you should check to see if the provider or medical facility is in your health plan’s network. Providers and hospitals that are considered in network contract with the plan and agree to accept a discounted rate for the services they provide. Health plans pick up more of the health care costs for in-network providers than out-of-network providers, which means lower costs for you if you stay in network.

Some health insurance plans, such as health maintenance organization plans, only reimburse you for medical services when you go in-network. Others, like preferred provider organization plans provide limited coverage when you visit an out-of-network provider. Regardless of your plan, you almost always pay less out-of-pocket when you get medical care in-network.

After a doctor’s visit, the provider typically submits a claim to your insurance company. Once the health insurance company approves the claim and pays its portion of the costs, the health insurer sends you an Explanation of Benefits (EOB).

The EOB details:
The services you received.
How much your plan covered.
What you owe the provider.

An EOB also includes information about out-of-pocket costs:
Health insurance deductible: Your portion of the annual health care costs before the company begins to kick in money.
Coinsurance: Your percentage of health care costs after reaching your deductible, such as 20% of costs paid by you and 80% paid by the insurance company.
Annual out-of-pocket maximum: The most you pay out of pocket for in-network care in a year.

Your doctor will send you the final bill. On the bill, you can see how much you’re responsible for paying the doctor after your insurance company has paid its portion. The bill will also include instructions for where and how to send the payment.

Question 2

Health Insurance Terms to Know

Accepted Answer

Health insurance is often associated with complicated terminology. Understanding these terms can help when shopping for a health plan and navigating health insurance.
Copays
A copayment, or copay, is a fixed fee you pay when you receive a specific medical service. Primary care visits often have lower copays than specialists and emergency care.
Deductibles
Your deductible is the amount you must pay before your health insurance company starts covering your medical expenses. Only in-network provider visits usually count toward your deductible. The deductible resets at the beginning of each year.
For example, imagine your health plan has a $1,000 deductible. You would need to spend $1,000 out-of-pocket on qualifying medical expenses before your insurance company starts paying its portion of the bill.
Coinsurance
Coinsurance is a percentage of each medical bill you must pay after hitting your deductible. Coinsurance is another form of cost-sharing—you pay a certain portion and your insurance company pays the rest.
Let’s say your health insurance policy has a 20% coinsurance for outpatient surgeries. You need to have knee surgery and end up with a medical bill of $8,000. In this case, you would pay 20%, which is $1,600, and your insurance company would pay the remainder.

Health insurance involves a range of terms and definitions that are important to understand when navigating health coverage. Here are some key terms and their definitions in the context of health insurance:
Premium: The amount you pay for your health insurance policy, typically on a monthly basis.
Deductible: The amount you must pay out of pocket for covered healthcare services before your insurance plan starts to pay.
Copayment (Copay): A fixed amount you pay for specific medical services or prescription drugs, typically at the time of service.
Coinsurance: The percentage of costs you share with your insurance company for covered healthcare services, after meeting your deductible.
Out-of-Pocket Maximum (OOPM): The most you will have to pay for covered healthcare services in a plan year, including deductibles, copayments, and coinsurance.
Network: A group of doctors, hospitals, and other healthcare providers that have agreements with your insurance company to provide services at discounted rates.
Out-of-Network: Healthcare providers who do not have agreements with your insurance company and may result in higher out-of-pocket costs.
Pre-existing Condition: A health condition or illness that you had before your current health insurance policy went into effect.
Open Enrollment Period: A specific timeframe during which individuals can sign up for or make changes to their health insurance plans without a qualifying life event.
Health Savings Account (HSA): A tax-advantaged account that allows you to save money for medical expenses when you have a high-deductible health plan.
Preferred Provider Organization (PPO): A type of health insurance plan that allows you to visit any healthcare provider, but you'll pay less when using in-network providers.
Health Maintenance Organization (HMO): A type of health insurance plan that requires you to choose a primary care physician and obtain referrals for specialist care.
Exclusive Provider Organization (EPO): A type of health insurance plan that only covers care from in-network providers, except in emergencies.
Marketplace (Exchange): An online platform where individuals and families can compare and purchase health insurance plans, often facilitated by the government.
Premium Tax Credit (Subsidy): Financial assistance from the government to help lower-income individuals and families afford health insurance premiums through the marketplace.
Medicaid: A government program that provides health insurance for low-income individuals and families.
Medicare: A federal health insurance program for individuals aged 65 and older, as well as certain younger individuals with disabilities.
Coordinated Care: An approach to healthcare that emphasizes communication and collaboration among healthcare providers to improve the quality and efficiency of care.
Essential Health Benefits: A set of healthcare services that must be covered by all insurance plans sold on the health insurance marketplace.
Inpatient Care: Medical services received when admitted to a hospital or healthcare facility for an overnight stay.
Preventive Services: Healthcare services and screenings aimed at preventing illness or detecting conditions at an early stage.
Explanation of Benefits (EOB): A statement from your insurance company that outlines the services provided, the amount billed, the amount covered, and what you owe.

These are just a selection of terms commonly used in the realm of health insurance. Understanding these terms can help you make informed decisions about your coverage and navigate the healthcare system more effectively.

Question 3

What Are the Different Types of Health Insurance?

Accepted Answer

There are five common types of health insurance plans. A health insurance plan’s design sets the parameters for how you get care and influences what you pay.
Health maintenance organizations (HMOs)
A health maintenance organization plan (HMO) plan typically only covers your medical expenses for in-network visits. If you go out-of-network, your insurance company doesn’t cover any portion of the bill. The only exception is emergency care, which is covered in-network and out-of-network.
HMO members generally choose a primary care provider who oversees and coordinates their care. If you need to see a specialist, you typically must get a referral from your primary care doctor.

Preferred provider organizations (PPOs)
Preferred provider organization (PPO) plans are the most common type of health insurance if you get coverage through an employer. PPOs offer more flexibility, such as getting covered for out-of-network care. If you have a PPO and go out of network, you typically pay more than if you stay in the plan’s network. PPOs also don’t require a primary care referral to see a specialist.
That flexibility generally comes at a higher cost than an HMO.

Exclusive provider organizations (EPOs)
Exclusive provider organization (EPO) plans are similar to an HMO, including the need to stay in network to get covered. One difference between an HMO and EPO is that you don’t need to choose a primary care provider in an EPO. You can manage your own care and make appointments with specialists without a referral from your primary care physician.
One way an EPO is similar to a PPO is that you don’t need to name a primary care provider.

Point-of-service (POS) plans
A point-of-service (POS) plan lets you get medical care in-network or out-of-network, but you will pay less if you stay in network.
POS plan members are required to work with a primary care provider. Referrals are also required to see a specialist, like an endocrinologist or oncologist. You may also need a referral to see an out-of-network specialist.

High-deductible health plans (HDHP)
A high-deductible health plan (HDHP) is a health insurance plan with a deductible of at least $1,500 for an individual or $3,000 for a family. Any health plan, like a PPO or HMO, can be an HDHP.
One of the biggest benefits of an HDHP is a lower premium. The downside is you pay more out-of-pocket when you need care until you reach the plan’s out-of-pocket maximum.

Pro Tip
When comparing health insurance costs, look at both premiums and out-of-pocket costs, such as deductible, coinsurance and out-of-pocket maximum.

Medicare
Medicare is a health insurance available to Americans age 65 and older, people with disabilities and individuals with End-Stage Renal Disease (ESRD).
Medicare comes in two forms—Original Medicare and Medicare Advantage.
Original Medicare includes Part A (hospital insurance) and Part B (medical insurance), with the option to purchase a separate Part D (prescription drug coverage) plan.
Medicare Advantage, also called Medicare Part C, is private health insurance. Medicare Advantage combines Parts A and B along with other coverages, including prescription drugs and benefits not found in Original Medicare, such as vision and dental care.

Medicaid and CHIP
Medicaid and the Children’s Health Insurance Program (CHIP) provide free or low-cost health insurance to low-income individuals, pregnant women and families. These programs are jointly funded by the federal government and state governments.
Each state has its own eligibility requirements for Medicaid and CHIP. These requirements are based on income level and household size. Other factors can influence eligibility, including age, whether you’re pregnant and if you have a disability. You can check your eligibility for these programs on HealthCare.gov.
You can apply for Medicaid or CHIP through the marketplace. There is no open enrollment for these programs, so you can enroll at any point during the year.

Question 4

How do I choose the right health insurance plan for my needs?

Accepted Answer

When we’re given a choice about our health care plans, we often choose badly.

In one study, more than 80% of the employees at a Fortune 100 company picked the wrong plans, often choosing low-deductible options that ultimately cost them more. Another study found that inertia — sticking with the same plan, rather than evaluating the options each year and choosing a better one — cost workers an average $2,032 annually.

These findings shouldn’t surprise anyone who has tried to compare multiple health insurance plans offered by an employer, an Affordable Care Act marketplace or insurers with coverage that supplements Medicare.

There are simply too many moving parts: what you pay each month (your premium), how much you have to pay before insurance picks up a larger share of the cost (your deductible), and the limit on how much you’ll pay in a year (your maximum out-of-pocket), for starters. There’s also how much you’ll owe for each doctor’s visit, test or prescription, which could be a flat amount (your co-pay) or a percentage (your co-insurance), or both. These amounts can vary not just by insurance plan, but also by the types of medical service you get, with different amounts for hospital stays, lab work, preventive care and so on. Which prescription drugs are covered varies from plan to plan and from year to year. So does the list of medical providers who are considered “in-network.”

But we owe it to our health and wallets to make the best choices we can during open enrollment. The following steps won’t guarantee you’ll pick the best plan, but they may help you avoid the worst.

Match your consumption to your deductible
Many experts recommend high-deductible plans for healthy people who rarely visit the doctor, since premiums for these plans are lower. But high-deductible plans also can be a good fit for people who need a lot of health care, says Carolyn McClanahan, a physician and certified financial planner in Jacksonville, Florida.

Parents of young children or people who have chronic health conditions often spend so much on care that they can easily meet a higher deductible, McClanahan says. Many high-deductible plans (those with deductibles in 2020 of at least $1,400 for individuals or $2,800 for families) qualify for tax-advantaged health savings accounts, as well.

These plans aren’t a good fit, however, for people who would put off necessary care rather than pay out of pocket. If you don’t have enough savings to cover medical costs until the deductible is satisfied, consider spending more for a lower-deductible plan.

Just don’t pay an extra $500 to lower your deductible by $250, as many people did in that first study. If you’re allowed to choose different deductibles for the same plan, multiply the difference in premiums by 12 to get your yearly cost and compare that to the difference in deductibles.

Call your doctors
If you have physicians and specialists you prefer, call their offices to ask if they are in the network of the plans you’re considering. It’s important to ask “Are you in network?” rather than “Do you take this insurance?” A provider who’s not in the network may be willing to bill your insurer, but you’ll typically pay a (much) larger share of the cost.

Do the ‘worst case scenario’ math
Some employers offer software that allows workers to upload their claims history from the past year and uses that to recommend a health care plan. I wish that were available to everyone. The closest I’ve seen is HealthSherpa, which helps people winnow their ACA marketplace options based on how they generally use health care.

The plan that may have been a good fit for your past claims, though, may not be the best choice for the future — especially if you become seriously ill or injured. To protect against worst-case scenarios, you also need to consider the “out-of-pocket” limits. These are the maximum amounts you’d have to pay in addition to your premiums. Out-of-pocket limits typically range from $2,000 to $6,000, although there may be different maximums for in-network versus out-of-network costs, and not all policies have these caps.

Some plans give you only a small break in premiums while exposing you to much larger potential costs, says Alan Silver, senior director of benefits delivery and administration at Willis Towers Watson, a benefits consultant.

Before signing up for any policy, add your annual premiums to the out-of-pocket limit to see the potential costs you could face. If the total scares you, look for a plan with a limit that lets you sleep at night.

Pro Tip: If you don’t expect to need much health care in the coming year, a Bronze or Silver plan could be a smart financial choice. But if you have a family, expect to start a family or you would rather pay more upfront and less when you need care, a Gold or Platinum plan would likely be a better decision.

Question 5

Can I keep my current doctor with my new health insurance plan?

Accepted Answer

If you're shopping for health insurance, you can prioritize keeping your doctors and prescriptions.

Healthcare.gov, state exchanges, and private exchanges all have tools that can help you check if your doctors and prescriptions are available on a given plan.

You can also talk to your doctor directly about which health insurance companies they work with.

Health insurance companies contract with networks of providers, and it's possible that your doctor is in a network that works with multiple insurers or is in multiple networks. Depending on their answer, you may have multiple companies that you're able to choose plans from when you start shopping for health insurance.

Additionally, you may want to look at a preferred provider organization, or PPO, health insurance plan. PPO health plans have networks of providers, but still allow you to see any doctor out of network. Out-of-network care may be more expensive than in-network care, but buying a PPO plan is one way to keep your current doctor while buying a new health insurance plan.

Question 6

How do I select a Primary Care Physician?

Accepted Answer

A primary care provider is a doctor who handles your routine health care. They are the person to see if you need a vaccination, have an upper respiratory infection or require help to manage a chronic health condition such as diabetes.

Your primary care provider also should monitor your overall physical, mental and emotional health. When your health problem requires additional care, the primary care doctor will refer you to a specialist, such as a cardiologist or an ophthalmologist. Primary care providers also are called primary care doctors and primary care physicians.

Although some people use urgent care or the emergency room for their primary care needs, that doesn't allow you to build a trusted, long-term relationship with one provider, says Dr. James Wantuck, chief medical officer and cofounder of the telehealth platform PlushCare. Wantuck is an internal medicine physician based in San Francisco.

By building a relationship over time, the provider becomes a detective, like a Sherlock Holmes, to find out what's wrong when something isn't right with your health.

Types of Primary Care Physicians

There are several types of doctors who work as primary care physicians:

A family medicine physician cares for the whole person through all stages of life, from infant to older age. They will focus on seeing you as a whole person rather than just one specific health problem, says Dr. Ada Stewart, president of the American Academy of Family Physicians and a practicing family physician in Columbia, South Carolina.
An internal medicine physician specializes in care for adults.
A pediatrician cares for children.
An OB/GYN can be a primary care provider for some women, particularly young, healthy women. However, OB/GYNs specialize in reproductive health and aren't equipped to handle problems like strep throat, COVID-19 or other problems beyond women's health. Also, many family medicine and internal medicine physicians will handle routine gynecological care, such as Pap smears.
A nurse practitioner or a physician assistant also can be a primary care provider. These providers work closely with a medical doctor, so if there's something they can't do, they'll refer to their supervising doctor, says Dr. Susan Besser, a primary care provider specializing in family medicine at Mercy Personal Physicians at Overlea in Baltimore. For instance, some states only allow medical doctors to prescribe certain types of medicines.
You also may wonder about the difference between an MD (medical doctor) and a DO for primary care. Both receive similar training, but DOs (short for doctor of osteopathic medicine) also study 300 to 500 hours of osteopathic manipulation, which is a hands-on approach used to treat the musculoskeletal system. Both MDs and DOs commonly work as primary care doctors.
If you have to choose a new primary care doctor because of a change in health insurance, a move or changing medical needs, for example, consider these following tips.
Choosing a New Primary Care Doctor 
Ask friends or family. 
Many referrals to a primary care provider come from friends or family members. Their recommendation can be helpful because that person knows you well. 
However, a stamp of approval from a friend or family member doesn't always mean the doctor is a good match for you. You'll have different health issues than your friend or family member. Plus, the personality mix of the doctor and patient together is the real key to a successful relationship, says Dr. Ruth Brocato, a primary care provider specializing in family medicine at Mercy Personal Physicians at Lutherville, Maryland. If a friend or family member likes a doctor, ask what they like about that provider. This will help you determine if there's a potential match for you.

Check online reviews. 
Online reviews are popular, but they should be a starting point, not the final say, when choosing a new primary care provider. It's always helpful if you see mostly positive reviews, as that likely indicates the doctor cares about his or her public image. No doctor wants to be the one on a review site with only one star, Wantuck says. However, negative reviews may not always be accurate, and all reviews are anecdotal.

Check the doctor's background credentials. 
This is usually easy to find on the practice website. You can use their online information to check the following:
Is the doctor licensed in your state? You can find out where a doctor is licensed to practice and their education background at the Federation of State Medical Boards website. 
What is the doctor's specialty: family medicine or internal medicine?
Is the doctor board certified? Board certification refers to a special exam that doctors can study for and pass after completing medical school, Wantuck says. Doctors aren't required to complete board certification, but it adds an extra layer of knowledge. Board certification also requires courses that refresh the doctor's knowledge every few years. 
If it's important to you, you'll also want to take into account if the doctor is male or female.

Ask about health insurance coverage. 
You can whittle down costs when you see a primary care provider who's covered by your private health insurance plan or Medicare or Medicaid. Many health insurance plans will require you to pay a small fee, or copay, for each appointment, and the plan will cover the remaining cost. Insurance plans have online tools so you can verify which local primary care providers accept your insurance.

You can also call your insurance company to find providers in your area. If you find a primary care provider you like, but their office doesn't accept your insurance, talk to the provider's staff. They may be able to arrange an affordable self-pay option. The same is true if you don't have any health care coverage. If you have health insurance, your plan still may pay for a portion of the appointment as an out-of-network visit, Wantuck says.

Consider the office location. 
How close is the office to your home? Beyond that, find out if there's parking or if the office is close to a bus or subway line. If you or a family member has special needs, ask in advance if the office has an elevator and ramps for wheelchairs and walkers, Stewart advises.

Ask how long it takes to get an appointment. 
You can do this by calling the office and simply asking them how quickly it usually takes to get an appointment. You'll also want to ask if they have same-day appointments in case you get sick and need to be seen urgently.

It also can be helpful to know how the doctor handles after-hours emergencies and non-emergencies, Stewart says. For example, is there another on-call physician, or does the office use an answering service to field nighttime calls? Another consideration nowadays: Does the office have telehealth appointments?

When visiting, consider how long your wait time is. 
You usually can expect some waiting at any doctor's office, but you'll want to make sure you're comfortable with the average wait time. That comes with a caveat, Brocato says. "Obviously wait time is important, and I aim to be on time, but realize that I may have been delayed because I was comforting a new widow or talking to a parent whose child is struggling in school or even giving a patient a new cancer diagnosis," she explains.

Evaluate how well the primary care provider listens. 
This is a huge factor in finding a new primary care provider, Wantuck says. Does the doctor take the time to listen to your concerns? Do you feel comfortable opening up to him or her?

As part of this, find out about their philosophy of medical care to see if you agree with it, Besser advises.

For instance, do they prefer to prescribe medications, or are they more interested in starting with lifestyle changes? Which do you prefer? The doctor's focus on prevention of chronic diseases, rather than only treating something once a condition develops, also can be important, Brocato says.

If you have a pre-existing condition such as diabetes or high blood pressure, ask if the doctor regularly treats patients with your condition.

Some patients may wish to ask if the doctor regularly treats LGBTQ patients, Stewart says.

Take cues from the office environment. 
Staff friendliness and office cleanliness can help indicate the type of care you'll receive.

When choosing a new primary care physician, you can set up a meet-and-greet visit to get a better feel for that person and the office. You'll find out more information during that visit to help with your decision, Besser says. You also can ask the doctor's office if they offer a trial period, so you can see over a few appointments if you feel comfortable going there. Even if they don't formally offer this, you should still be able to look for a new primary care provider when you want to switch to someone new.

As you try to pinpoint the right primary care provider, keep in mind that it's a collaborative relationship. You don't want to contact the provider only when you're sick. Stay in touch for preventive care appointments, immunizations and when you need emotional or mental health support, Stewart says. By staying in touch, the provider gets to know you better, and that helps to build a stronger relationship.

Question 7

What Is an Out-of-Pocket Maximum? Definition and How It Works

Accepted Answer

What Is an Out-of-Pocket Maximum? 
An out-of-pocket maximum is the most you have to pay per year for covered healthcare services. When you have spent this amount in your plan year on deductibles, copayments, and coinsurance for in-network care and services, your health insurer will pay for 100% of your healthcare services.

An out-of-pocket maximum helps you to control the cost of your healthcare because you know the maximum you will ever have to pay in a year. The out-of-pocket maximum for marketplace plans can't be above a set amount each year. For the 2022 plan year, this amount is $8,700 for an individual and $17,400 for a family.

Out-of-pocket maximums help individuals and families avoid major financial problems associated with high healthcare costs in years when they need a lot of treatment. There are some exceptions, though, so make sure you understand what is and isn't covered. Otherwise, you may end up with a nasty surprise. 
An out-of-pocket maximum, also referred to as an out-of-pocket limit, is the most a health insurance policyholder will pay each year for covered healthcare expenses.
When this limit is reached, your health plan will cover 100% of your qualified expenses.
You can generally choose from a range of plans with different out-of-pocket limits. However, plans with lower out-of-pocket maximums normally have higher premiums, and those with higher out-of-pocket maximums have lower premiums.
Some individuals (or families) may qualify for lower out-of-pocket maximums if they earn under certain income thresholds or meet other requirements.

Understanding Out-of-Pocket Maximums 
In general, an out-of-pocket maximum is the most you have to pay per year for covered healthcare services. When you have spent up to this amount on your healthcare in a year, your healthcare insurer will pay for 100% of your healthcare costs. Deductibles, copayments, and coinsurance all count toward your out-of-pocket maximum under the Affordable Care Act.

In practice, however, it's a little more complicated than that.

For example, there are some costs that aren't included in your out-of-pocket maximum. These include: 
Your insurance premiums
Anything you spend for services your plan doesn't cover
Out-of-network care and services
Costs above the allowed amount for a service that a provider may charge
These exceptions mean that even when you reach your out-of-pocket maximum for the year, you will still have to pay your premiums to stay covered. You should also be careful to use in-network healthcare providers if you want to control the costs of your healthcare, because out-of-network costs don't count toward your out-of-pocket maximum.

Also, costs that aren't considered covered expenses don't count toward the out-of-pocket maximum. For example, if the insured pays $2,000 for an elective surgery that isn't covered, that amount will not count toward the maximum. This means that you could end up paying more than the out-of-pocket limit in a given year.

Out-of-pocket maximum limits
The highest out-of-pocket maximum you will have to pay is controlled by federal law. The government has set limits that control how much healthcare insurers can charge for covered services per year. These are: 
For the 2022 plan year: The out-of-pocket limit for a Marketplace plan can’t be more than $8,700 for an individual and $17,400 for a family.
For the 2021 plan year: The out-of-pocket limit for a Marketplace plan can’t be more than $8,550 for an individual and $17,100 for a family
Choosing an out-of-pocket maximum 
Different healthcare plans have different out-of-pocket maximum limits, so you may have a choice when it comes to your out-of-pocket maximum. 
In general, you should choose the plan with the lowest out-of-pocket maximum. This will keep the maximum amount you spend per year as low as possible. However, insurance companies balance the out-of-pocket maximums they offer against the premiums they charge. 
This means that plans with low out-of-pocket maximums have high premiums and vice versa. For example, Health Insurance Marketplace Bronze and Silver health plans generally have lower monthly premiums and higher out-of-pocket limits. The Gold and Platinum plans, which have higher monthly premiums, typically have lower out-of-pocket limits

Question 8

What is the difference between in-network and out-of-network care?

Accepted Answer

What does in-network mean?
In-network refers to a health care provider that has a contract with your health insurance plan to provide health care services to its plan members at a pre-negotiated rate. Because of this relationship, you pay a lower cost-sharing when you receive services from an in-network doctor.

What does out-of-network mean?
Out-of-network refers to a health care provider who does not have a contract with your health insurance plan. If you use an out-of-network provider, health care services could cost more since the provider doesn’t have a pre-negotiated rate with your health plan. Or, depending on your health plan, the health care services may not be covered at all.

Is it more expensive to see a provider outside of my health plan’s network?
Yes, typically you’ll pay more if you go to an out-of-network provider. Keep in mind that some health plans don’t have any coverage for non-emergency services received from an out-of-network provider. Be sure to check your benefits before picking a doctor or other health care provider

Question 9

Do I need referrals to see specialists with my health insurance plan?

Accepted Answer

Whether or not you'll need a referral depends on what type of health plan you have. Typically, PPOs and EPOs do not require a referral to see a specialist. However, if you're seeing someone who is out of your network, you'll need an OK from your insurance provider first.

Things You Need to Know About Getting a Medical Referral
Imagine. You or your family member has a scratched eye. Maybe it’s ongoing stomach pain or a rash on your arm at random times of the year. Whatever the illness, it’s a medical ailment that goes beyond what your general doctor can handle. It’s time to call a specialist, right?

Not so fast.

In the United States, many health insurance companies will not allow you to just call up a specialist and make an appointment. If you want them to pay for it, you’ll need to get a referral first.

What’s a referral, and how do you go about getting one? We cover the details of seeing a specialist in the US:

What is a referral?

Certain types of health insurance companies will not allow you to see a specialist unless you have a referral from your primary care physician (PCP). He or she will determine what kind of a specialist you need to see and recommend one (or a few) who they trust.

For example, with some plans, you cannot see a dermatologist or gastroenterologist unless you see your general doctor first. This is similar to getting a prescription for medication.

Your doctor’s office will help coordinate the visit with the specialist and share your health details with them. They will also communicate this to the insurance company. Before you see the specialist, double check that the referral went through. If the specialist wants to see you again, make sure that the referral covers more than one visit.

How do I know if my insurance requires a referral?

It depends on the type of insurance that you have. Simply said, health maintenance organization (HMO) plans and point of service (POS) plans will require a referral before seeing a specialist. On the other hand, preferred provider organization (PPO) and exclusive provider organization (EPO) plans do not require a referral.

You can easily find out which type of plan you have by looking on your health insurance card.

Are there any exceptions?

Women do not need a referral to see an in-network obstetrician-gynecologist for routine care, such as Pap smears and mammograms. Also, visits that the insurance company considers an emergency may not need a referral.

What if I don’t get a referral?

There’s nothing to stop you from seeing a specialist without a referral, but the problem is that you will be responsible for the full cost of the visit. The insurance company will not cover it. So instead of paying a copay, you’ll be stuck with a much higher bill.

What if I don’t have a PCP?

Unfortunately, if your health insurance requires that you get a referral, there’s no way around it. Some insurance companies will assign you a PCP, so you can call that doctor to make an appointment with them.

It’s always best to establish a PCP before you’re sick. Make an appointment to establish yourself as a patient at their office. That way, your doctor will have your full medical history and will be able to see you sooner (and the appointment will be faster!) when you are sick.

What if I can’t wait to get a referral?

If the situation is serious and you need to see a specialist immediately, you might want to consider going to an urgent care facility or the emergency room. Neither require an appointment, but you will have to wait for a doctor to have an opening to see you.

Question 10

How does prescription drug coverage work with health insurance?

Accepted Answer

As the population ages, spending on prescription drugs has been increasing faster than other aspects of our health care costs. From 1994 to 2003, prescription drug spending rose at double-digit rates each year. And it's still rising, although the increase can now be measured in single digits [source: Kaiser Family Foundation]. A few changes in the world of prescription medication have contributed to this slight slowdown in spending -- including the way health insurance companies offer prescription drugs. Many insurance plans have excluded high-cost drugs from coverage, cut down on refills and increased co-pays.
There has been much debate and research on how insurance companies can profitably meet our prescription drug needs. Let's find out what's going on.
Any insurance plan's prescription drug coverage includes a formulary, or a preferred drug list. It contains the medications your plan prefers and that can usually be prescribed without any prior authorization. This list is created to keep the drug costs down for the insurance company while still offering you a competitive choice of medications. One main purpose of the formulary is to encourage you to use the generic form of a given drug. If you don't choose the generic, some plans will charge more. Others may ask for the price difference plus the normal co-pay, some have a deductible for name-brand drugs and others will simply deny the coverage altogether.
A formulary can have several forms, depending on your exact insurance plan. Some plans will cover drugs that are on the formulary (preferred drugs, usually generic) and not on the formulary (nonpreferred drugs, usually brand-name), but you will generally have to pay more for nonpreferred drugs. Other insurance plans may be more cut-and-dried, covering only those drugs on the formulary and denying payment for all others without some sort of preapproval process. 
However, the majority of formularies fall somewhere in between these two types of plans and into a "tiered" formulary. In these plans, drugs are assigned to a tier, with each tier increasing the co-pay amount. Normally, in a three-tier plan generic drugs are found at the cheapest tier-one level. Tier two includes brand-name drugs in which generics are not available, and tier three contains drugs that aren't found in the formulary, or are nonpreferred, and thus are charged an even higher co-pay.
If your doctor prescribes a drug that isn't on your health insurance plan's formulary, most plans have an authorization process in which a drug may be approved on a case-by-case basis. Usually in these situations, you must have already failed with the approved treatments or experienced adverse effects from them. If your coverage is still denied, an appeal process is usually available.
So, how is a formulary created? Your insurance company has a committee that is normally composed of physicians, pharmacists and other health care providers. This committee selects drugs and other products on the formulary, keeping in mind factors like safety, efficacy and quality, along with the cost to the insurance company. Most formularies are reviewed and revised on a quarterly basis. New FDA-approved drugs may be added to the list, and noneffective or expensive older drugs may be removed.
So what happens if you can't afford the co-pays, or if you can't afford health insurance altogether? Salvation may come from the oddest places. Find out where in the next section.
Patient Assistance Programs 
Patient assistance programs can help the uninsured get the medications they need. 
Some of us with health insurance struggle to pay for our prescriptions, so imagine how hard it would be if you had a chronic condition and no insurance. Luckily, patient assistance programs -- funded by state governments, charitable organizations and even drug companies -- can come to the rescue.
Yes, pharmaceutical companies are one of the main providers of free or discounted medication to low-income patients without insurance. Most major drug companies offer Pharmaceutical Assistance Programs (PAPs), which provide discounted or free medication to those who qualify. Some drug companies may also provide qualifying customers with a discount drug card.
If you qualify for these programs, it usually means you earn too much to qualify for government-funded programs but don't make enough to afford your own health insurance. Or maybe you can't get health insurance based on your medical history and can't afford all of your medications. Each PAP has different criteria, which can be confusing for people on medications from different drug companies. So the drug industry launched the Partnership for Prescription Assistance (PPA) to help patients find the right assistance fast. The PPA provides information on more than 475 PAPs and can help patients contact Medicare or other government programs that could be of use. Several other agencies provide the same services -- Access to Benefits Coalition specializes in the aging population and Medicare information, and NeedyMeds offers information from drug companies, state and local companies and programs based on specific diseases.
Saving Money on Prescription Drugs
Americans spend more on pharmaceuticals per capita than residents of any other country. Here's some advice on how to save some money.
Talk to your doctor: He or she could know about nonprescription options or another brand of the drug that costs less.
Check into your state's drug assistance programs.
Find out if you qualify for drug assistance from a PAP.
Compare prescription prices online and at your neighborhood pharmacy -- prices can vary dramatically.

Question 11

What’s the open enrollment period, and can I get covered outside of it?

Accepted Answer

The open enrollment period for health insurance is a set period of time during which individuals can enroll in or make changes to their insurance coverage. This period is generally established by the government or insurance providers, and its purpose is to ensure that individuals have a guaranteed opportunity to enroll in coverage or make changes to their existing coverage. It is also a way to balance the financial risk for the insurance providers. By having a set period during which individuals can enroll or make changes, insurance providers can better predict and plan for the number of individuals who will be covered under their plans. This helps them to better manage their costs and ensure that they have enough funds to pay for the healthcare needs of their customers. It is important to note that there are some exceptions to the open enrollment period such as special enrollment periods triggered by certain events like loss of coverage, marriage or birth of a child.

To summarize, open enrollment is needed because group health insurance plans -- and all individual health insurance plans -- are now guaranteed-issue. Without the open enrollment periods, people would just wait to buy coverage until they got sick or needed an expensive medical procedure.

What is a pre-existing condition, and how does it affect my coverage?
A health problem, like asthma, diabetes, or cancer, you had before the date that new health coverage starts. Insurance companies can't refuse to cover treatment for your pre-existing condition or charge you more.

Question 12

How can I file a health insurance claim?

Accepted Answer

In most cases, you do not have to file your own health insurance claims; your health provider usually files the claim for you after services are rendered. However, there are some circumstances under which you may need to file your claims yourself. If you have a fee-for-service indemnity plan, you may be required to file your own claim.

In most cases, you do not have to file your own health insurance claims; your health provider usually files the claim for you after services are rendered. However, there are some circumstances under which you may need to file your claims yourself. 
If you have a fee-for-service indemnity plan, you may be required to file your own claim.
If you have a Preferred Provider Organization (PPO) plan or a plan that includes a Point of Service (POS) option, you may have to file your own claims if you seek help from an out-of-network provider or at an out-of-network facility, as when traveling.
If you have a short-term health insurance plan, you may need to file your own claims.
If you are covered by Medicare, doctors and suppliers are required by law to file claims for you within 12 months of providing those services or supplies. However, if they fail to do so, you may need to file a claim. If it is nearing the 12-month deadline and your provider has not filed the claim, call 1-800-MEDICARE (1-800-633-4227). Ask for the exact time limit for filing a Medicare claim for the service or supply you received. If it's close to the end of the time limit and your doctor or supplier still hasn't filed the claim, ask them to direct you to information on filing the claim yourself.
These are a few examples of times when you may need to file claims yourself. Read your own plan documents closely to make sure you understand all of your coverage and services, and be sure to retain paperwork about your health claims.

https://www.sharecare.com/health/health-insurance/do-file-own-insurance-claims
What is the process for appealing a denied claim or coverage decision?
Appeals Patients and Providers can file an appeal. Internal appeals are submitted to the health insurance company directly. Call the health insurance company for instructions. External appeals must be filed within 60 days of the final adverse determination. Health plans may charge providers a $50.00 fee per appeal.
It’s no secret that people and their insurance companies sometimes clash over which medical services will be covered.
Here are answers to some of the most frequently asked questions about health reform and filing grievances with insurers.

Q: If you feel your health insurance company is not following the new laws, who do you contact?
A: If you have reason to believe your insurance company is not complying with provisions under the Accountable Care Act you can contact your state’s department of insurance to file a complaint.
If you get your health insurance through your job, it’s also a good idea to discuss your concerns with your human resources department. Or you can contact the U.S. Department of Labor’s Employee Benefits Advisors for help by calling 866-444-EBSA (3272).

Q: How long will the appeal process take or how soon should I expect the matter to be settled?
A: You’re entitled to appeal directly to your insurer if it:
denied payment for your care
ruled that your care was not medically necessary
said that you’re not eligible for the benefit in question
claimed that your treatment is experimental
claimed that you have a pre-existing condition
The new law sets the following timelines for insurance companies to review and decide on an appeal:
72 hours for denials of urgent care
30 days for denials of nonurgent care you have not yet received
60 days for denials of service you have already received

Q: What if my appeal with my insurance company is denied?
A: If your appeal is denied, you are entitled to an explanation from your insurer. The plan is also required to explain how you can go about filing an external appeal, in which your case is reviewed by an independent third party.
Keep in mind that if your case is urgent and you or a loved one are in danger of becoming increasingly ill without treatment, you can ask to have both the internal review and external review conducted at the same time.

Q: Is that appeal process already available? If not, when does it take effect?
A: For many people, internal and external appeals processes are already available. If your health plan went into effect on or after March 23, 2010, your insurer must comply with these laws as of Sept. 23, 2010.
If you have a plan that was in place prior to March 23, 2010, however, it may qualify for grandfathered status and the new guidelines for appeals may not apply. You can learn more about grandfathered health plans and what it means for you at the web site of Families USA, a nonprofit advocacy organization.
However, even if you have a grandfathered health plan, you should check with your insurer and/or state department of insurance about your right to appeal. Most states -- 44 -- already offer an external appeal process, although the laws vary greatly. All health plans are encouraged to adopt the new regulations prior to July 1, 2011.

Q: If I have a grievance and I'm appealing my insurance company's decision, what do I do in the meantime?
A: Ask your insurance company to continue paying for your treatment until a determination on your appeal has been made.
If your request is refused, it’s a good idea to speak with the doctor or hospital treating you. Ask to arrange a payment plan or if collections can be put on hold until your appeals process is complete.

Q: If I don't pay a contested medical bill, will it ding my credit?
A: Yes. It’s important that you don’t ignore medical bills. Instead, work with your health care provider to arrange a payment plan so your bills are not sent to a collection agency, which providers can be quick do. That can damage your credit rating.
If your bill has already been sent to collections, speak with the collections agency and ask to pay the bill right away. But don’t send a penny until you get the agency to agree to remove the bill from your credit report.

Question 13

What is the Affordable Care Act?

Accepted Answer

Signed into law on March 23rd, 2010, The Patient Protection and Affordable Care Act (ACA) is also known as healthcare reform. Healthcare reform is not health insurance. Healthcare reform is law that makes changes to the insurance system. These changes help many more people get health coverage. They also protect consumers more than ever before.

The California Department of Insurance (CDI) regulates insurance in California - including health insurance. We continue to work hard to put these reforms in place. Our goal is to protect consumers, foster the insurance marketplace so that it is vibrant and stable, and enforce the law fairly and impartially.

How does health care reform affect me? 
If you have health insurance, you probably have already seen some of the changes in your policy. For example, most policies now let you keep your children on your insurance until age 26. Insurers cannot deny you coverage because if you have an existing health condition. And most policies now provide preventative services, such as immunizations, birth control, mammography and many other cancer screenings, with no out-of-pocket cost to you. Here are more changes:
If you get sick, an insurance company cannot cancel your policy.
Health insurance companies cannot turn down your application because of your health status.
Women can no longer be charged more for insurance than men. In fact, insurance rates cannot be based on gender or gender identity at all.
Once you buy health insurance, you do not have to pay anything for preventive care.
No more annual dollar limits on coverage for essential health benefits.
No more lifetime limits on essential health benefits.
Insurance companies have to spend at least 80% of your premium dollars on actual medical expenses, not overhead and profit.
Medi-Cal will cover more low-income individuals and families (all individuals under 138% of the federal poverty level are eligible).
As part of healthcare reform, California law states that there must be a minimum set of benefits in most health insurance policies. These are called Essential Health Benefits or EHBs. Some policies sold prior to January 1, 2014 are "grandfathered" and do not have to cover Essential Health Benefits. Below is the list of the EHB categories.
Essential Health Benefits include:
Hospital care
Visits to a primary care doctor and specialists
Outpatient procedures, like surgery
Laboratory tests and diagnostic services, like x-rays and mammograms
Pregnancy and newborn care
Preventive and routine care, like vaccinations and checkups
Mental health care
Emergency and urgent care
Rehabilitation therapy, such as physical, occupational and speech therapy
Some home health or nursing home care after a hospital stay
Prescription drugs
Substance abuse treatment
Oral and vision care for children
Affordable Care Act marketplace 
The Affordable Care Act (ACA) marketplace at Healthcare.gov allows you to purchase individual or family health insurance from participating insurance companies. Some states run their own health insurance exchanges, while others are part of the federal marketplace.
There are no income requirements to get ACA coverage and marketplace plans are the only ones eligible for premium tax credits and subsidies. Those credits and subsidies can save you money on health insurance based on your household size and income.
Affordable Care Act marketplace plans are the only health plans eligible for premium tax credits and subsidies, which help reduce the cost of health insurance.

ACA marketplace plans are sold in metal tiers: Bronze, Silver, Gold, and Platinum insurance plans. These tiers are based strictly on premium and out-of-pocket costs.
Here’s how the metal tiers differ:
Bronze plans: Lowest premiums but highest out-of-pocket costs.
Silver plans: Higher premiums than Bronze plans but lower out-of-pocket costs.
Gold plans: Higher premiums than Silver plans but lower out-of-pocket costs.
Platinum plans: Higher premiums than Gold plans but lower out-of-pocket costs.

If you do not have coverage – Health Care Mandate 
Healthcare reform makes health coverage available and more affordable for millions of Americans. It gives subsidies for those who purchase private insurance and California expanded Medi-Cal to include more people and single adults. Together with the opening of Covered California's online marketplace, it is easier than ever to get health care coverage. Please see our Getting Health Coverage section for more information about your options.
If someone who can afford coverage does not purchase it, they may have to pay a tax penalty. This is called the shared responsibility payment and sometimes also called the "individual mandate." Some people may qualify for an exemption, but you can find more details about this by visiting Healthcare.gov.

Federal Health Insurance Plans
You might consider a federal health insurance plan if you can’t get health insurance coverage through your employer. These plans are funded at least partially by the government and provide comprehensive health coverage.

Question 14

What is a High Deductible Health Plan (HDHP)?

Accepted Answer

A high deductible health plan (HDHP) is a health insurance plan with a higher deductible and lower monthly premiums than a traditional health plan. HDHPs are often a good fit for people who are generally healthy and don't expect to need much medical care.

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