Navigating through insurance information can be overwhelming for the novice. Understanding insurance participation will help you make the most of your insurance and keep you from losing benefits or paying for items and services which are covered. Most places that accept insurance will help you with figuring out how to fill out forms and make claims; however, it is also wise for you to have at least a basic knowledge of how insurance systems work.
Types of Insurance Coverage
Insurance coverage varies from company to company and plan to plan. Some of the most popular types of coverage are:
• PPO – Preferred Provider Organization
• EPO – Exclusive Provider Organization
• POS –Point-of-Service Plan
• HMO – Health Maintenance Organization
• Catastrophic Plan
• High-Deductible Health Plan (Health Savings Account optional)
Payment options depend upon the company and type of insurance. Participation in an insurance plan usually requires a premium. This is the monthly amount you pay for the insurance. Premiums can vary depending on the deductible. The deductible is the amount you are required to pay before your insurance covers any services beyond essential benefits. For example if you have a $1,000 deductible, you would need to pay this amount out of pocket before the insurance begins to pay for services. At that point the health plan usually covers 100% of the charges.
Insurance participation may require you to pay certain fees at the time of service. Co-payments are the fees that are paid at the time of service. This is an amount that is usually the same each time you visit your doctor or clinic. Co-insurance payments are made when your plan requires you to pay a percent of the charges. You may pay 20% of the charges when you make a co-insurance fee. This amount varies depending on the charges. Co-payments on the other hand always remain the same. Co-payment charges can vary and they also count toward your deductible.
Out of Network Providers
Many insurance plans will charge fees when you see a doctor that is not in your insurance network. Some may require you to pay the difference between what a company doctor would charge and what an out of network doctor charges.
Insurance Participation Paperwork
There are very few people who enjoy filling out forms. Thankfully, there are usually few forms to fill out with insurance participation, particularly when you are working within the provider network. There will be a few forms initially and that is usually all that is needed.
This may change if you need to see a doctor outside the network. This can happen when you get ill out of town or in an emergency situation where you may not be able to see a provider within your insurance company’s network.
If you have questions about your insurance coverage, don’t hesitate to ask us about it. At PCP for Life, we have people who can walk you through the process and make sure you are getting the most out of your insurance.