With healthcare, along with the economy, being at the center of this years presidential campaigns it is more important than ever to understand health insurance and the many terms associated with it.
While the vast majority of doctors and healthcare providers are of the highest integrity, patients should understand what their insurance covers and what the terms of that coverage means. This will allow you to track what your financial responsibility will be and what the insurance will pay for.
Basically speaking, health insurance is a contract. The insurance company provides payment for treatment as long as your premium due them is paid up to date. In most cases coverage is not 100%, so you must understand exactly how much you will be responsible for after the insurance company pays their share.
This brings us to the term Deductiable. A deductible is how much you will pay "up front" prior to any money paid by the insurance provider. Normally these will be in increments of $250, $500, $1,000 or more. The higher the deductible, the less you pay as a premium. But remember, whatever the deductible is, will come out off (your) pocket before the insurance company pays anything. Deductibles may be for individuals or families combined. They are also an annual total, so they begin again with each year of coverage.
Copayment (COPAY) is the dollar amount you will owe each time you visit a doctor or purchase medicine and is a predetermined, fixed figure as per your policy. There is also something called Coinsurance, which applies to a total medical bill and is normally stated as a percentage. The most popular split is 80/20 with the 20% being the patients responsibility.
Sometimes the doctor or hospital will require an Approval or Authorization number from the insurance company before providing any services.
Non covered charges are as they sound. Anything that is "non covered" will not be paid or reimbursed by insurance.
Pre Existing Condition is at the core of "Obamacare" where insurance companies would have no choice, but to accept a patient even if that person was already suffering from an illness. As it stands today, many carriers refuse to accept an individual under these circumstances.
There are Waiting Periods setting forth a timeframe prior to insurance beginning, even after the policy is accepted by both parties. Grace Periods may be granted allowing for late premium payments before your coverage will be cancelled.
Exclusions refer to anything not covered by the insurance plan and almost all policies have a Lifetime Mahimum, when, if exceeded, your coverage will end. Again, they can be individual or family and are usually high amounts in excess of $1,000,000.
If you are on a partners policy, but also have one of your own, the two insurance companies will work out a Coordination of Benefits with both satisfying part of the bill.
You should always carry your insurance card and a copy of any for your children, with you along with a photo ID. The doctor or hospital will require the policy number in advance of services provided. If you are expecting a child, it is a good practice to be sure you are covered for pre natal and birth care well in advance of the event. Failure to include this new addition to your family may result in an insurance company's refusal to pay.
If it turns out that any coverage was denied "after the fact", you and your doctor should ask for a detailed reason for the denial and file an appeal if necessary.
Some common reasons for payments being denied range from the obvious non payment of premium or treatment provided that is not covered, to failure to receiving prior approval and forms not being filled out properly.
One last bit of advice would be to verify that the doctor or hospital is not Out of Network meaning the health insurance provider and the party providing the services do not have an agreement to work together.
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