Health insurance coverage helps minimize the financial costs associated with medical care. It is a wise investment because accidents and illness can happen to anyone at anytime. The cost of medical care is high. However, before you get care or reach out to anyone about the care you need, you must know your health insurance coverage and where to get that help.

Understanding Your Health Insurance Coverage

When you sign up for health insurance, your documentation outlines your coverage. Many companies also put these documents, called your summary of benefits and coverage, on the online portal to your account. Please read through them. Be sure you know what your coverage includes.

That will provide a list of the care covered under your policy, including the coverage amount and any related restrictions or requirements. Some examples include:

• Coverage for your primary care doctor – which is typically the main doctor you will go to for most needs
• Coverage for specialist needs
• Preventative care screenings and tests, along with immunizations coverage
• Coverage for prescription medications
• Coverage related to outpatient surgery that does not require an overnight stay
• Emergency room and urgent care center care and coverage
• Hospital stay coverage
• Mental health care services
• Home health care services and coverage
• Pregnancy and delivery care coverage

When choosing health insurance, carefully examine each area to determine which could provide you with the level and support you need.

Insurance Verification

Insurance verification occurs when you set an appointment or visit a medical provider. That should happen before you receive care. In short, it allows you to confirm that your health insurance will cover the care you are about to receive.

Typically, scheduling professionals for doctors and medical care providers will handle the insurance verification process. Verifying your coverage does not charge you anything. Still, it will allow the doctor to provide you with detailed information about:

• How much coverage you have.
• If that provider or service is covered at all.
• Any restrictions or first steps that are required.
• How much your out-of-pocket costs could be.
• The maximum benefits provided.

You can verify this cost information with any provider before you obtain service. Be sure to ask these questions.

In-Network vs. Out-of-Network Providers

Most health insurance policies offer coverage for both in-network and out-of-network providers. In-network providers are medical professionals and services that have a direct contract with the insurance provider. The policy generally covers their care either fully or partially. Opting for in-network providers usually results in lower out-of-pocket costs for the insured individual.

Out-of-network providers are either partially covered, covered at a reduced rate, or not included in the coverage provided by your insurance company. Consequently, if you seek services from an out-of-network provider, you will be responsible for paying more out-of-pocket for the received services.

Pre-Authorization and Referral Requirements

In some situations, you will need permission to get care for a specific need before you see that provider. For example, many insurance companies require that a primary care doctor provide a referral before a patient sees a specialist. That may include a specialist for surgery, kidney health, heart-related health, etc.

Also notable is pre-authorization. In some situations, you need to formally request authorization from the insurance company for the services you wish to receive from that provider.

Billing and Claims

Once you take all the necessary steps to verify your insurance and head off to the doctor’s appointment, you may not think much else is to come. However, you must pay close attention to the billing and claims process.

When you receive a bill in the mail:

• Verify that you received the specific care outlined on the bill.
• Verify that your insurance is covering that cost as expected.
• Look at the “patient responsibility” section – this is the amount you will likely pay.
• Note that the insurance company may take time to process the claim.
• If there are any questions about the care or the amounts presented, contact the doctor’s office for more information and guidance. Do not assume your insurance company can tell what care you received.

There are some situations where you may need to file a claim for coverage. That means you have already received the care and must now submit a claim to the insurance company. Follow the specific steps your insurance company requires to do this.

Additional Coverage Options

Take the time to learn about all of the coverages you have, as well as restrictions. Many insurance policies can have add-on coverage to meet additional needs. That may include:

• Dental Insurance
• Vision insurance
• Hearing aid coverage

Also, most insurance companies will not cover fertility treatments, cosmetic procedures, or off-label medication use. You may purchase insurance that provides that type of care, though.

Finding Help from an Insurance Agent or Healthcare Advocate

Health insurance and coverage are confusing in every situation. That is why it is so important for you to have all the resources you need available. Turn to an insurance agent or a healthcare advocate for more insight into your coverage options and needs. Most importantly, get clarification on anything you do not understand before you agree to the coverage.