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The “From Coverage to Care” initiative has been designed to help people with new health care coverage understand their benefits and connect to primary care and the preventive services that are right for them, so they can live a long and healthy life. The Navigator program is working across the state providing education to consumers. Our role is to share these resources with consumers, and help them on their journey From Coverage to Care.

Now that you have health insurance it is important to understand what it is and how to use it.

You can get started by learning the answers to these three important questions:
(click the questions to reveal the answers)

What is health coverage?

It is a way to help pay for health care. It protects you from paying the full costs of medical services when you have an unexpected illness or injury. It works just like home insurance or vehicle insurance. You choose a plan and agree to pay a certain rate (called a premium) each month. In return, your health insurance provider agrees to pay a portion of your covered medical costs based on the type of plan you select. Payments made by your health insurance provider are typically based on rates they negotiate with doctors and hospitals. These rates will determine what you pay when you receive medical care, so be sure to read over your policy in order to know how much you are responsible for paying before you receive care.

What are preventative services?

Preventative Services are meant to help keep you healthy. They may also catch some diseases in the early stages of development, which allows for better treatment and lower costs for care. Examples include vaccinations, colonoscopies, mammograms, and certain blood tests. Most plans now must cover a set of preventative services at no cost to you. If you have more questions about Coverage to Care, click here for our list of preventative services.

What is a primary care physician?

A primary care physician (abbreviated as PCP) is just another term for your family doctor, or the doctor you see for most of your basic medical needs. A primary care physician focuses on preventive care and the treatment of routine injuries and illnesses (like the flu or a broken finger). They will refer you to a specialist if necessary. Check with your provider to determine whether or not you have to designate a PCP. Some plans require it and will automatically select a PCP if you don’t. You can always change your PCP at any time by contacting your health insurance provider.

Key Health Insurance Terms

Network – medical facilities and doctors your insurer has contracted with to provide health care services.
Premiums – your monthly bill.
Deductibles – amount you pay before your Coinsurance kicks in.
Copayments – fixed amount you pay for a covered health care service.
Coinsurance – What you pay after you have fulfilled the deductible.
Out-of-pocket maximum – the most you pay during a policy period.

Reading Your Insurance Card

InsuranceCard

  1. Member name and date of birth – These are usually printed on your card
  2. Member Number – This number is used to identify you so your provider knows how to bill your health plan. If your spouse or children are also on your coverage, your member numbers may look very similar.
  3. Group Number – This number is used to track the specific benefits of your plan. It’s also used to identify you so your provider knows how to bill your insurance.
  4. Plan Type – Your card might have a label like HMO, PPO, HSA, Open, or another word to describe the type of plan you have. These tell you what type of network your plan has and which providers you can see who are “in-network” for you.
  5. Copayment – These are the amounts that you will owe when you get health care.
  6. Phone Numbers – You can call your health plan if you have questions about finding a providers or what your coverage includes. Phone numbers are sometimes listed on the back of your card.
  7. Prescription Copayment – These are the amounts that you will owe for each prescription you have filled.

How do I find providers in my network?

  • It is important to choose the right primary care physician and emergency medical facility for yourself and your family. You will generally want to choose a physician who accepts your insurance in order to pay lower out-of-pocket costs. Be sure to call your Health Insurance Company or state Medicaid and LaCHIP Program to find out what health care providers are in their network. Your health insurance provider can also send you with a book of in-network physicians and medical facilities at your request. You can also look at your health insurance provider’s website to search for providers by name, location, or specialty.

What are some tips for choosing a doctor?

  • Doctors in your provider’s network will be cheaper.
  • Ask friends and family for recommendations.
  • The closer to home the better.
  • Be comfortable with your choice.

How do I schedule my first appointment?

  1. Don’t forget health insurance documentation and photo identification.
  2. Brush up on your family medical history.
  3. Bring a list of medication you currently take.
  4. Make a list of concerns about your health and don’t be afraid to ask questions if you don’t understand anything.

  1. Decide if your provider is right for you.
  2. Stay in contact with your primary care physician for preventative care.
  3. Follow through with you providers recommendations.
  4. Keep receipts for any payments you have made.

 

Following Up with Your Payments – Explanation of Benefits

MedicalBill_Benefits

  1. Service Description – A description of the health care services you received, like a medical visit, lab tests, or screenings.
  2. Provider Charges – the amount your provider bills for your visit
  3. Allowed Charges – the amount your provider will be reimbursed; this may not be the same as the Provider Charges
  4. Paid by Insurer – the amount your insurance plan will pay to your provider
  5. Payee – the person who will receive any reimbursement for over-paying the claim
  6. What you owe – the amount the patient or insurance plan member owes after your insurer has paid everything else. You may have already paid a portion of this amount, and payments made directly to your provider may not be subtracted from this amount.
  7. Remark Code – a note from the insurance plan that explains more about the costs, charges, and paid amounts for your visit

Appeals and Grievances

  • If you have a complaint or are dissatisfied with a denial of coverage for claims under your health plan, you may be able to appeal or file a grievance. For questions about your rights or assistance, you can contact your insurance plan or state Medicaid or LaCHIP program.