Where to begin with your insurer
After purchasing private individual health insurance coverage, it is important to learn the policy terms and how the different processes work for coverage, claiming, and billing. This can help a person avoid any unexpected coverage difficulties and costs.
Since coverage and out-of-pocket costs vary among insurers, understanding these areas can help a person make decisions when shopping for a policy.
Becoming familiar with the processes involved in billing can help an individual know which payments providers expect at the time of service and which payments they expect later.
This article discusses coverage and prior approval, as well as in-network versus out-of-network providers. It also examines billing and claims and suggests questions to ask an insurance company.
Knowing what coverage includes
Knowing the coverage options that an insurer offers means becoming familiar with the extent to which it pays for the medical treatment a person may need.
This will typically include inpatient and outpatient charges, as well as any general coverage exclusions. Exclusions are things that the insurance does not cover.
The term “inpatient” refers to hospitalization and charges incurred during a hospital stay, while “outpatient” refers to services such as doctor consultations and lab tests.
A person also must consider the cost of a monthly premium. Often, the higher the monthly premium, the fewer out-of-pocket expenses a person will have.
Additionally, an individual should review their policy documents to learn about coverage for:
- medications
- special conditions or treatments, such as pregnancy, physical therapy, and psychiatric care
- home care or nursing home care
- specialist consultations, such as with eye doctors and dentists
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In network or out of network
Some, but not all, private health insurance providers have a network of hospitals, doctors, and other healthcare professionals that they contract with to offer medical care to policyholders at an agreed-upon fee.
Any doctor or facility not listed as or considered “in network” by an insurer is usually an out-of-network provider. This means a person may have to pay a higher cost for treatment. In some cases, insurers may not cover any out-of-network costs.
