Plan Basics

Basics of Health Insurance Plans

Knowing how health insurance works really helps when it comes to getting the best medical care at the lowest cost.

What you need to know

Are you confused about health insurance? The majority of people are. A solid understanding of the basics will help you to decide the best plan for your family.

All health insurance plans rely on provider networks. Some networks are very broad and give a lot of choices while others are very narrow and limited.

♦ Using providers in your plan's network is the key to limiting your costs.

What’s a provider network?

A provider network is a list of the doctors, other health care providers, and hospitals that a plan has contracted with to provide medical care to its members. Some plans call these providers in-network providers or simply preferred providers

A provider who doesn’t have a contract with your health insurer or plan is referred to as an out-of-network or a non-preferred provider. You’ll pay more to see a non-preferred provider.

♦ Insurers generally can’t require higher copayments or coinsurance if you get emergency care from an out-of-network hospital, no matter what type of plan you have.

• It is important understand it must be care that is truly emergency related and for which you reasonably believed could have been life threatening. Your insurance company will likely challenge out-of-network charges before agreeing to pay.

Out-of-network providers may bill you for additional costs not reimbursed by your insurance. This is called balance billingwhich is part of a larger problem called Surprise Billing.

Accept My Insurance

Do you accept my insurance?

This is a risky question.

Even if the doctor’s office staff answers yes, it does not always mean the doctor you are planning to see is in your plan’s network.

It could just mean they are willing to bill your insurance company.

You really need to confirm with your insurance company that the doctor or other provider is in your plan's network.

The best way is to call the customer service number on your insurance card and ask your insurer to confirm this.

How can I see if my doctor is in a network before I choose a plan?

• First, make a list of all the providers you use.

Remember that providers include health care professionals like doctors, psychologists, physical therapists, and health care facilities like hospitals and urgent care clinics.

Pharmacies and clinics located inside pharmacies are part of networks too.

• If you are considering individual insurance through Obamacare, you can compare plans offered at the Marketplaces before you enroll.

Start by visiting HealthCare.Gov. The plans on the exchange will link to the insurance companies offering the plans.

Your state may use their own exchange instead of the federal one. The article Marketplace provides a list for state run exchanges.

You also have the option of going directly to the websites of insurance companies you are interested in.

♦ Insurance companies may have different networks for different plans, so make sure you’re searching the correct provider network of each specific plan you are considering.

You also can call the health insurance company’s customer service phone number to check if your providers are in the plan’s network.

If you travel a lot, check to see if the plan’s network has providers where you might need care.

♦ If you are enrolling in a plan during open enrollment (Nov. – Dec.) the online search lists are not reliable.

You should call the company’s customer service number and ask to confirm your provider will be in the plan starting next year.

♦ Just because the provider accepts the plan this year does not guarantee they will accept the plan next year.

You need to confirm this, especially if keeping your family doctor or specialist is most important for you.

Why do some plans pay for network providers, but not out-of-network providers?

When a provider is a network provider for a plan, it means that the provider provides services at prices that the provider and the plan have already agreed on.

The provider is obligated to accept the agreed reimbursement. This means you usually receive services at a lower cost than someone without insurance, or someone with insurance but through a plan in which the provider is not in their network.

♦ All Marketplace plans are required to have provider networks with enough types of providers to ensure that their plan members can get plan services without unreasonable delay.

Unreasonable delay has not been well defined so this can become a point of contention.

♦ If you use an out-of-network provider, you may have to pay the full cost of the benefits and services you get from that provider if you plan does not allow for out-of-network.

The exception would be for emergency services.

♦ If you get emergency services from an out-of-network provider, those services are covered by a Marketplace plan as if you used an in-network provider.

However, providers may bill you for some additional costs associated with the emergency services you get. This is a situation where Surprise billing is a real problem.

♦ If the provider is out-of-network they are not obligated to accept what your plan may decide to reimburse them.

The provider may try to bill you for the balance. This is often referred to as balance billing.

If this turns out to be a large sum you should first appeal your insurance company’s decision and try to get them to pay more.

• After the appeal is completed and you still owe a lot, you should ask the provider to reduce the bill.

Most providers are willing to accept considerably less if they understand you cannot afford to pay all but can pay some.

Network Gap Exception

If you have a condition that requires treatment by a specialist, and your plan’s network has no appropriate specialists, you may qualify for what is referred to as a network gap exception.

Most health insurance plan documents don’t actually say network gap exception.

Your description of benefits might read: Coverage for services from non-participating providers requires prior approval.

♦ There are different rules for qualifying for an exception depending upon the insurance company and the plan you have.

The horror stories of the many obstacles abound but do not give-up.

A network gap exception allows you to see an out-of-network provider but have the same cost as if you were seeing an in-network provider.

How to get a gap exception?

You need to request a network gap exception from your insurance company.

♦ You must make this request prior to obtaining any services.

You can start the process but often times your primary care physician will make the request because medical documentation will be needed, such as diagnosis and procedure codes.

Your insurer will determine:

• First, is the requested service covered by your plan?

• Second, is the service medically necessary?

• Third, is there a provider in your network who is capable of providing the service you are requesting?

♦ Insurance companies fear increased costs if they approve a gap exception because they do not have a contract with these providers.

At the same time, they are under some pressure because of the Affordable Care Act to make sure their plans provide the coverage they promise.

♦ All Marketplace plans are required to have provider networks with enough types of providers to ensure that their plan members can get plan services without unreasonable delay.

It is very unclear what is considered an unreasonable delay.

Reasons for a gap exception

• There is no in-network specialist of the type you need to see within a certain mileage radius. Your insurance plan sets that distance requirement.

• You are already on a treatment plan with a provider and that provider suddenly leaves your network.

You ask for a gab exception to complete your treatments from the same provider.

The more specialized the treatments the greater the chances are of obtaining a gap exception.

Keep in mind the exception will be limited to the time needed to complete the treatments.

• You are traveling and out of your network area. If it is not a true emergency you need to call and request an exception for the services.

♦ Asking for a gap exception so you can keep your favorite doctor will not fly.

You and your doctor have to make a sound case for the exception.

If your request is denied, don’t give-up. You can appeal the decision but first you need to find out why it was denied.

It may simply be because your doctor failed to provide all information.