Getting your insurance to approve your procedure is half the battle. Understanding your coverage is the other half. There is nothing more frustrating than receiving information from your insurance that you don't understand. There are some key terms that your insurance uses that can be confusing. We will try to explain some of those terms for you now so that you can better understand your coverage and responsibilities through your insurance plan.
A referral is an authorization from your insurance company for you to see a specialist. A referral has to be requested by your primary care doctor and submitted to your insurance company. Referrals are not always required for you to see a specialist; it depends on your insurance plan. Insurance plans that require referrals are Secure Horizons and all HMO plans.
A co-payment is an amount that your insurance has assigned you to pay when you have a medical appointment. The amount of your co-payment may be different depending on what kind of appointment you have. Your co-payment at your primary care doctor may be different than your copayment at a specialist's office. Your co-payment amounts are listed on your insurance card, and are due at the time you have your appointment.
Your deductible is the amount of money that you have to pay out of pocket before your insurance will start to pay. Deductible amounts are different with every insurance plan. Also, some types of appointments don't apply to your deductible, meaning that you don't have to meet your deductible before your insurance will pay for them.
Even after you meet your deductible, some plans require you to pay a co-insurance. The co-insurance amount is usually a percentage that your insurance company requires you to pay for every claim that they pay on. For example, if you have a 10% co-insurance and your insurance company gets a claim for $100.00, they will pay $90.00 and you will pay $10.00.
OUT-OF-POCKET MAXIMUM OR COST-SHARING CAP
This is the maximum amount of money you have to pay out of your pocket per year. This amount does not usually include your deductible or co-payments, but does include your co-insurance payments. After you reach your out-of-pocket maximum, your insurance covers your claims at 100%, so you no longer have to pay co-insurance amounts.
Your insurance company makes contracts with doctors and facilities to provide care at lower costs. If you see a doctor, or go to a facility that has a contract with your insurance, you are going to an in-network provider. This means that your costs are reduced because your insurance company's costs are reduced. It is in your best interest to go to an in-network provider. Either your insurance company or the provider you want to see can let you know whether or not they are in your insurance company's network.
Some insurance plans do not offer out of network benefits, so you will want to check with your insurance company before you go to a provider that is not contracted with your insurance. If your insurance does provide out-of-network benefits, you will usually end up having more out-of-pocket costs because out of network benefits usually have a higher deductible and higher co-insurance amounts.