General Health Insurance Benefit Information
Trying to understand your insurance coverage is often confusing, especially regarding what it covers or does not cover. We provide some basic information for your review. However, we recommend you check with your insurance carrier prior to seeking treatment for your specific benefits.
Health Insurance usually covers the following:
Pays for part of your medical bills if your medical care that does not require prior authorization.
Provides coverage preventive care services, like cancer screenings or annual check-ups.
Depending on your insurance coverage you may have coverage for the following:
- Blood pressure, diabetes, and cholesterol tests
- Many cancer screenings, including mammograms and colonoscopies
- Counseling on such topics as quitting smoking, losing weight, eating healthfully, treating depression, and reducing alcohol use
- Regular well-baby and well-child visits, from birth to age 21
- Routine vaccinations against diseases such as measles, polio, or meningitis
- Counseling, screening, and vaccines to ensure healthy pregnancies
- Flu, Covid 19, and pneumonia shots
More specific benefit information is listed in the taps below.
Along with confusing health benefits is the coverage terms you need to know:
Premium: This is the monthly payment you make to have insurance. Think of it like a gym membership or car payment. You still must pay the same amount each month even if you do not use the coverage that month.
Deductible: Some insurances charge a deductible, which restarts every year. It is the predetermined amount that you must pay for health care services before your health coverage is available. Deductibles are most common with HMO coverages.
Copayment (also known as a copay): To keep the insurance carriers’ costs down, some insurance plans have copays. These are usually fixed amounts you pay each time you see a medical provider.
Coinsurance: Not the same as a copay, coinsurance is a percentage of your bill that you pay after you have paid your yearly deductible. For example, if you have a 20% coinsurance, you pay 20% of the bill and your insurance pays the remaining 80%, once you have met your deductible.
Out-of-Pocket Maximum: This is the maximum you will have to pay out of your own pocket for covered health expenses. Once you hit the maximum, your insurance will pay 100% of your health care costs for covered services for the remainder of the year.
HMOs is a Health Maintenance Organization. An HMO is a network of doctors, hospitals and other healthcare providers who agree to provide care at a lower fee. HMOs often require you to select a primary care physician (PCP), and all specialist services must be approved by the PCP when needed. HMO plans are generally less expensive than PPO plans, with lower monthly premiums, making them cost effect if your doctors are already in the network.
PPOs is a Preferred Provider Organization. Like an HMO, a Preferred Provider Organization is a network of doctors, hospitals and healthcare providers who agree to provide care at a certain rate. Unlike an HMO, you are not limited to providers who are in that network. PPO plans generally require higher monthly premiums than HMOs. With a PPO, you do not need to designate a primary care physician and usually can see the provider of your choice at any time, including specialists.