Using Your Health Coverage - 6/17/2019 Edition

Cover Page

Using Health Insurance Coverage

You have health insurance coverage. Great news – now you’re covered! But what’s next? You’re probably going to use that coverage to access to health care treatments and services.

How you access health care (and when) will determine what your health plan will pay or if a service will be covered – and that will ultimately impact what you pay out of pocket for your health care.

This tool will give you basic information about health insurance and help you better understand how your health plan works so you can make good decisions about your health care.

Note: There are different ways to get health insurance and different types of plans. This tool does not include details about how to use Medicaid [States can customize to identify state Medicaid plan by name], Medicare, or other types of health plans like short-term or supplemental policies. The examples in this tool are general and do not reflect your health insurance plan. See the Health Insurance Resources section to get information about help with Medicaid, Medicare and other types of health plans.

This tool has information to help you, and here are a few basic tips to get you started. You will find more information in the sections that follow.

Always carry your insurance card with you. It has basic information about your health coverage

and tells your doctor and other health care providers who is covered. Show it when you check-in at your provider’s office or go to the pharmacy.

Understand how your insurance plan works. The best way to avoid unexpected medical bills is to

understand your health plan and what your costs will be ahead of time. Pay your monthly premiums on time. Your insurance plan may be canceled if you don’t pay on time

and you may not be able to sign up again until next open enrollment period. If you have a problem paying your bill, call the Assister who helped you enroll, your insurance company, or one of the 800 numbers at the bottom of this page.

Managing your care and out of pocket costs. Pick a Primary Care Provider in your insurance

plan’s network. This can be a doctor, nurse, or physician assistant.

Prescription drugs Know what to do in case of an urgent or emergency medical situation. Know what you should do if you have a health procedure or a surgery. You’ll want to be

sure the hospital or facility and all health care providers are in your plan’s network so you don’t have to pay more out of pocket. You’ll also need to find out if the procedure requires prior authorization by your plan.

Update your plan if something in your life changes. Life is unpredictable. If you get married,

divorced, have a baby or adopt, your health coverage needs change. Make sure you keep your plan updated on any life changes.

Getting to Know Your Health Plan

Maybe you can’t remember the details about your plan – what it covers, what it doesn’t or what your out-of-pocket costs may be.

Don’t worry. You can get that information when you need it. Here is where you can find information about your coverage or get help understanding your benefits.

Check your insurance card. Your insurance card contains some of the most important information you need to access your health coverage. It tells health providers basic information about your coverage and who is covered. Most insurance cards will list toll free phone numbers and website information where you can access the most current information for your health coverage.

Check the SBC. Ask your insurance company or employer for a Summary of Benefits and Coverage (called an “SBC”). This is a short list of your benefits and what the deductibles, co-pays and coinsurance amounts (called cost-sharing) are.

Check the policy. Make sure you have a copy of your policy or plan certificate (if you get your health coverage through your employer). Your plan information should include a document called a “Schedule of Benefits”. The Schedule of Benefits has more information about your costs and benefits. It also tells you the services that are not covered.

Contact the health plan. If after looking, you still have questions about your coverage, call your health plan. Or, you can ask your health insurance agent, insurance company, or employer to explain things.

My Health Insurance Card

Your insurance card contains some of the most important information you need to access your health coverage. It tells health providers basic information about your coverage and who is covered.

Keep the card with you at all times, but protect your insurance card like you would other sensitive personal and financial information.

Sample Insurance Card

Member Service: 800-XXX-XXXX

PCP Co-Pay $15.00Specialist Co-Pay $25.00 Emergency Room Co-Pay $75.00Prescription Group # XXXX

Prescription Co-Pay$15.00 Generic$20.00 Name Brand

Member Name: Jane Doe Member Number: XXX-XX-XXX

Group Number: XXXXX-XX

Insurance Company Name

Plan Type

Effective Date

Schedule of Benefits

A schedule of benefits is a list of the various services covered under a health insurance plan, along with the associated fees. Policyholders receive these schedules so that they know which services and treatments are covered and which are not. Some treatments and services may require a co-pay.

A Schedule of Benefits is a document that outlines the fees associated with each type of health care service covered by your plan. This includes: Your deductible and out-of-pocket max amounts.

A schedule of benefits would list various preventative, hospital, diagnostic, therapeutic, and urgent care services, among others. For example, under preventative services, the schedule may list "Adult physical examination (1 exam per calendar year)," "Vision exam (1 every 12 months)," and "Hearing exam (2 per calendar year)," alongside the co-pay costs for each service.

The Schedule of Benefits are usually broken down into several sections:

Heading: This is where the basic information about your health coverage is identified – what type of health plan (HMO, POS, EPO, PPO or Indemnity), who the plan is through, the benefit year and the effective date of coverage for the health plan (not when you were covered). You can learn more about the different plan types on page xxxx.

Your Responsibilities: This area identifies the deductible, copayments, coinsurance and tells you what the annual out of pocket maximums are. You can learn more about the different types of cost-sharing on page xxxx.

Your Benefits: This area lists the specific common benefits and what you will be responsible for in terms of the cost-sharing.

Pharmacy: This area identifies the pharmacy benefits under your health plan and the copayment information. You can learn more about how to utilize your pharmacy benefits on page xxxx.

Dependent Coverage: This section lists which dependents are covered and through what time frame.

Summary of Benefits and Coverage (SBC)

Your identification card will have some information about your coverage and the cost-sharing to help you figure out what your out of pocket costs will be. But, when you need more in-depth information, the Summary of Benefits & Coverage (SBC) is a great resource. The SBC is an easy-to-read summary of costs and coverage of health plans.

You’ll get the “Summary of Benefits & Coverage” when you shop for coverage on your own or through work, renew or change coverage. If you don’t have an SBC request an SBC from the health insurance company or your employer.

My Health Coverage

In the below area, jot down information about your health plan and cost-sharing from your Identification Card, your Schedule of Benefits or your SBC.

Then read the next few pages to understand what the different terms mean and how they are calculated.

My plan is: an HMO a PPO an EPO I don’t know

Co-Pay: A fixed fee paid directly to the provider when you get medical care (for example, $10 for every primary care visit).

My Co-Pays:Primary Care:

Prescriptions:

Specialist:

Emergency Room:

Deductible: The amount of money you must spend each year on your medical care before your insurance plan starts paying. Insurance may pay for some preventive services, like an annual physical, even if you have not met your deductible.

My Deductible: Family Deductible:

Coinsurance: A percentage you pay for most medical care even after you meet your deductible (for example, some insurance companies pay 80% of the bill so your coinsurance bill would be for 20% until you reach your Out-of-Pocket Maximum).

My Coinsurance:

Out-of-Pocket Maximum: The most you pay during a policy period before your health insurance or plan starts to pay 100% for covered services. This maximum does not include your monthly premium.

My Out-of-Pocket Maximum: Family Out-of-Pocket Maximum:

Monthly Premium: A fixed amount that you pay each month for your insurance plan. If you miss payments or pay late, your coverage could be canceled.

My Monthly Premium:

Different Kinds of Plan Networks

See page xx to learn more about in-network and out-of-network providers.

How You and Your Health Plan Share Costs—Example

Jane’s Plan Deductible: $1,500 | Coinsurance: 20% | Out-of-Pocket: $5,000 | Co-Pay: $0

Pick a Primary Care Provider in Your Network

Pick a Primary Care Provider (PCP) from your insurance plan’s network of providers. You will pay the least money out of pocket if you use providers in your health plan’s network. That’s because the health plan has negotiated contracts with the providers.

If you use a provider outside of your health plan’s network, you will pay more. And, your insurance plan may not pay anything for care with non-network PCPs or specialists.

Your PCP is your “medical home” where you call or visit each time you need medical care. They keep your medical record and help you get services from any specialists or other health professionals that you need.

Providers include a wide variety of health professionals: Doctors, Nurse Practitioners, Mental Health Specialists (also called Behavioral Health Specialists or Counselors), Dentists and others.

(Continued)

Pick a Primary Care Provider in Your Network (Continued)

To find the names of providers near you who are in your insurance plan’s network, you can:

• Contact your insurance company by phone. This number is on your insurance card.• Look on your health insurance company’s website.• Look in your insurance handbook to see which providers will accept your plan.• Call your provider’s office. Ask them:

1. Do you take my insurance?2. Are you in my plan’s network?

Your insurance company may assign you to a PCP. Usually you can change providers if you don’t like the one they assigned you. Contact your insurance company to find out how.

If you need special treatment, be sure to check on whether your local hospital or specialists are part of your plan’s network.

Avoiding Balance Billing

Get Your Prescription Medicines

Insurance plans help pay the cost of some prescription medicines. You may be able to buy other medicines, but those on your plan’s approved list, called the “formulary,” usually cost less (look on page 13 for information on categories of prescriptions). Always give your pharmacy your health insurance card. Prescriptions that you pay for will count toward your out-of-pocket maximum.

To find out which prescriptions are covered through your plan:

• Visit your insurance company website.• Call your insurance company directly to find out what is covered.

Different levels or categories of prescriptions:

$ Tier 1—Generic drugs$$ Tier 2—Preferred, brand-name drugs$$$ Tier 3—Non-preferred, brand-name drugs. These are also brand-name drugs, but are “non-preferred.”$$$$ Tier 4—Some plans use this tier for specialty drugs, while other plans have a separate “specialty” tier.

If the pharmacy says that your insurance plan doesn’t cover your medicine, some insurance companies may provide a one-time refill. Ask your insurance company if they offer a one-time refill until you can talk about next steps with your provider.

You can ask your insurance company to make an exception for you, so you can get a prescription medicine that’s not normally covered by your insurance plan. Your provider must tell your insurance plan that you need this drug because:

•All other drugs covered by the plan have not worked or will not work as well as the drug the provider has prescribed.

•All other drugs covered by your insurance plan have caused or could cause harmful side effects.

It is a good idea to talk with your providers about the best affordable medications for you, based on your plan.

Get the Most Out of Your Insurance Plan

Get preventive care to keep you healthy, avoid emergency room visits, and save you money. Many insurance plans include coverage of Essential Health Benefits to help you stay healthy, including:

• Care for new mothers and babies• Counseling and substance abuse services• Prescription medicines• Laboratory services• Help in managing diseases like diabetes or high blood pressure• Other preventive and wellness services• Services for kids (for example, vision checks)

Some of these services may be covered before you reach your deductible. Some preventive services are free!

Note: All Qualified Health Plans purchased through the Health Insurance Marketplace cover the Essential Health Benefits. Some grandfathered plans or employer-provided plans from outside the

Marketplace do not.

What to Do in Case of an Emergency

Only use an emergency room if you have a real emergency, such as any severe pain, like chest pain or stomach pain.

Urgent care facilities, sometimes called Quick Care, Express Care, or First Care, are a good choice when you need to see a provider quickly, but your life is not in danger. They almost always cost less than going to the emergency room.

Contact your insurance company to ask about in-network urgent care facilities near you.

If you have an emergency or life-threatening situation, call 9-1-1 or go to the nearest emergency room. In an emergency, you should get care from the closest hospital that can help you. Your insurance company can’t require Prior Authorization before going to the emergency room. Your insurance company can’t charge you more for getting emergency room care at an out-of-network hospital. You may still have to pay for emergency services, depending on your plan.

If you’re not sure what option you need, don’t be afraid to call your doctor. They’ll be able to help you decide what is necessary for your situation.

See page xx to learn about in-network and out-of-network providers. The difference in cost of different kinds of care looks like this:

Primary Care Visit Specialist Visit Urgent Care Visit*Emergency Room Visit

$$$

$$$$$$$$$$$$$$$

*If your plan has co-pays, your co-pay for urgent care may not be much more than your co-pay for a doctor visit.

Referrals and Prior Authorizations

If you need a special treatment, service, or medical equipment, sometimes you need to get approval in advance from the insurance company. This is called Prior Authorization. Prior Authorization is when your insurance company requires that a decision be made that the service is medically necessary before you receive it. You can ask your provider whether or not you need Prior Authorization.

Coordination of Benefits

If you are covered by more than one health insurance policy, all of your health plans will work together to pay their fair share of your health care costs.

You need to report if you have coverage under more than one health plan to your doctors and to your health plan. Coordination of benefit rules determine which health plan is primary and which is secondary.

Your insurance claim will then be processed by one health plan first and any remaining amount that is not paid will be paid by the other plan(s). The plans will not pay more than 100% of the treatment cost, so you're not going to get double the benefits if you have multiple health plans. And, you will still have to meet any deductibles under all plans before any secondary plan begins to pay claims.

But remember, having multiple plans doesn’t mean that everything will be covered. Coordination of benefits will only happen if the medical service or treatment is covered by both health plans. So, if you have plastic surgery to improve your looks and neither health plan covers plastic surgery, then neither plan will cover those expenses.

Here's an example of how COB works: Let's say you visit your doctor and the bill comes to $100. The primary plan picks up its coverage amount. Let's say that's $50. Then, the secondary plan picks up its part of the cost up to 100% -- as long as the services are covered by that insurer.

(from insure.com) Here is a list of situations and which plan would likely serve as primary and which ones would likely be secondary:

You're married and both you and your spouse have separate health plans - Your employer's plan is usually considered primary for you. Your spouse's plan would be secondary.

A child has dual coverage by married parents - In this case, the so-called "birthday rule" will apply. This means whichever parent has the first birthday in a calendar year is the one whose insurance plan is considered primary. Remember - it's not who is oldest. It's where the birthday (month and day) falls in the calendar year. If parents have the same birthday, the primary coverage will go to the plan that has covered a parent longer.

A child has divorced parents - The child is usually covered by the parent who has custody. If the child’s custodial parent remarried, the step-parent’s plan may provide secondary coverage for the child.  The plan of the parent who doesn't have custody usually pays last. If it's joint custody, the birthday rule usually applies. Note: A divorce decree may also influence which plan is primary.  If the divorce states that one parent is financially responsible for the healthcare expenses of the child, then that parent’s plan should be primary for the child and the other parent’s policy is secondary.  If the decree states that both parents are responsible, then their plans would be given the same priority, thus reverting back to the birthday rule for whose would pay first.

A child has own policy (from school or work) and still on parent's policy until 26 - The child's health plan is primary; the parent's plan is secondary.

A child is married and on spouse's policy and continues on parent's policy until 26 - Getting married doesn't change the health insurance status for a parent's policy, you can stay on it until you're 26. So, it's the same as if you're not married -- the child's or child's spouse's health plan is primary; the parent's plan is secondary.

A child under 26 is pregnant and on a parent's plan - The health insurance status would stay the same for the under 26 child; the parent's insurance serves as secondary. However, the newborn is different. Once the child is

born, he/she will need to be covered by his/her parent - not his/her grandparent.  The grandchild is not a dependent to the grandparents, thus their insurance would not extend to that child.

Workers' compensation and health insurance plan - If you get injured on the job, workers' comp pays first.

COBRA and other insurance – If you have COBRA and coverage from another plan which you are enrolled in with your employer, your employer’s plan is primary and COBRA is secondary.

Medicare and a private health insurance plan - Medicare is considered primary if the private insurance is a group plan with 100 or fewer employees. Private group insurance plans with more employees will have Medicare as secondary. Medicare is primary if the private plan is an individual policy.

Medicaid and a health insurance plan - Medicaid is always the payer of last resort when there are multiple plans.

Veterans Administration (VA) and a private health insurance plan - VA is not considered a health insurance plan. Instead, the VA bills public or private health insurance providers for care, services, prescriptions, and supplies. So, if your spouse has a health insurance plan it would be your health plan. The VA is not insurance.

Military coverage (TRICARE) and other health insurance - TRICARE is considered secondary to all other health plans except Medicaid, TRICARE supplements, state crime compensation programs and other specified federal government programs.  Note: If you are on active duty you can’t use any other health insurance.  TRICARE is your only health insurance coverage.

5 tips for dual health insurance coverage

Here are some tips to help you with dual health insurance coverage:

1. Make sure that your doctors are in-network for both insurance companies.

If your provider is in-network for your primary insurance but out-of-network for your secondary insurer, the secondary company may pay, but it could be at the out-of-network rate.

2. Make sure to follow the plan delivery rules for each insurer if you have multiple plans.

One example is one insurer may require prior authorization for certain services, while another may not. This is especially true if your insurance plans have different types of plan design, such as a PPO and an HMO. Don't assume that both insurers have the same rules.

3. Check what's considered a covered benefit and for any exclusions under each plan.

You don't want to get an expensive test thinking that both plans will cover it and find out later that the secondary insurance company doesn't cover that service.

4. Be proactive to avoid claims issues.

Communicate with both insurance companies before receiving care to make sure everything is covered.

5. Present both cards when you get services, so the billing is correct.

Avoid headaches and payment hang-ups by presenting both the primary and secondary cards to your provider.

Life Changes – Your Health Coverage Should Too

Family changes – Marriage, Divorce, Birth or Adoption of Child, Child aging off of coverage

Job changes – Lose job, FMLA, Disability, change jobs – COBRA, SEP, Medicaid

Retirement/Medicare -

Know How to Appeal an Insurance Company Decision

You will get an “Explanation of Benefits” (EOB) from your insurance company after you visit a doctor, clinic, or hospital. It tells what services they paid or did not pay for, and why. If they did not pay for a service you think they should have, you can appeal their decision not to pay.

Your insurance company must explain in writing why they denied coverage within a set amount of time. They also must let you know how you can appeal their decisions. If the timeline for the appeals process would seriously put your life at risk, or risk your ability to fully function, you can also file an “expedited” appeal that would get you a quicker decision.

If you need assistance filing an appeal, you can contact [State Insurance Agency] Consumer Assistance Program:

[(800) xxx-xxxx ][TTY: (xxx) xxx-xxxx | State Website]

You can also contact [State Insurance Agency] to file a complaint and start an investigation against an insurance company. The [State Insurance Agency] encourages you to call about any problems you have with a claim denial or service you receive from your insurance company.

Health Insurance Resources

The Health Insurance Marketplace is a resource where individuals, families, and small businesses can learn about their health coverage options; compare health insurance plans based on costs, benefits, and other important features; choose a plan; and enroll in coverage.

1 (800) 318-2596 | TTY: 1 (855) 889-4325 | HealthCare.gov

Your state department of insurance regulates the insurance industry through examining and licensing procedures of insurance companies, licensing producers, reviewing rates and coverage forms, conducting audits, and by sponsoring programs that enhance awareness of and compliance with State laws.

Consumer Assistance Hotline:1 (800) | website | other phone number

Notes

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