What to Know About Insurance When Going to the Doctor

doctor filling out patients insurance information on a clipboard

Medical services can be costly without health insurance. Even common illnesses and minor injuries can cost thousands, and severe ones cost significantly more. Unfortunately, not every employer offers benefits, and not every worker qualifies for governmental health insurance programs.

It’s essential to have health insurance to avoid astronomical costs. Still, it can be overwhelming to understand how it works, what your plan covers and the various associated terms. This guide will review basic information and terms associated with using health insurance at a doctor’s office.

How to Get Health Insurance

First and foremost, you must know how to get health insurance before you learn how to use it. You can get insurance from:

  • Your employer or spouse’s employer, if they offer it.
  • Government programs like CHIP, Medicaid or Medicare.
  • A parent’s plan until you reach a certain age, typically 26.
  • Your college, if it offers student plans.
  • An insurance agent or company.
  • A membership association or union that offers coverage.
  • The federal insurance marketplace.

Insurance you obtain through a job or association is group insurance. Health insurance you buy directly is individual insurance. You can add your family to individual or group plans.

If you buy insurance through the marketplace, you must buy it during the annual open enrollment period. You can purchase individual insurance at other times if you have a qualifying life event such as divorce, marriage, birth or adoption.

Types of Health Insurance Plans

There are four main types of health insurance plans:

  • Exclusive provider organization (EPO): This type of plan only covers medical services when you use in-network providers, except in an emergency.
  • Health maintenance organization (HMO): HMO plans often focus on wellness and prevention. Like EPOs, they only cover in-network care, except in an emergency. You may have to live or work in the plan’s service area to be eligible for coverage.
  • Point of service (POS): A POS plan lets you use out-of-network providers, but you pay less for using in-network medical providers. You often need a referral for this insurance to cover specialist services.
  • Preferred provider organization (PPO): With PPO plans, you pay less when you use preferred or in-network providers. You can use out-of-network providers, but you will have to pay more.

Marketplace health insurance plans further separate into “metal” categories:

  • Bronze: The insurance company pays 60% of your medical costs, so you pay 40% of them. They have lower monthly premiums, but the cost of services is higher.
  • Silver: With silver plans, the insurance company pays 70% of your medical costs and you pay 30%. They have moderate monthly premiums and moderate care costs.
  • Gold: The insurance pays 80% of your medical costs and you pay 20%. The monthly premium is high, but care costs are low.
  • Platinum: In platinum plans, the insurance company pays 90% and you pay 10%. It has the highest monthly premium but the lowest medical care costs.

The services covered by health insurance plans will depend on your kind. However, federal law requires many preventative care services to have no cost.

Health Insurance Terms

Here are some health insurance terms that are good to know when visiting the doctor:

  • Deductible: The deductible is what you pay before your insurance covers services. An aggregate deductible is what your family must meet. The insurance uses the cost you pay for one member’s services or a combination of family members’ services to reach the deductible. Embedded deductibles are ones individual plan members must meet with their service costs.
  • Allowed amount: This is the amount your insurance will pay for your health services. If you exceed it, you might be responsible for paying the difference.
  • Coinsurance: The coinsurance is the percentage of a bill you pay for a covered service or product. If you have a deductible, you pay the coinsurance after you meet it.
  • Copayment: This is how much you pay for a health service, usually the day you receive it. For instance, a trip to the doctor may cost $15 because you have a $15 copay for your primary care provider visits. These amounts vary based on if you use an in-network or out-of-network provider.
  • Disallowed amount: Disallowed amounts are the difference between what your provider billed and what the insurance paid. They are not billed to you.
  • Excluded services: Health services not covered by your plan.
  • Health insurance portability and accountability act (HIPPA): This is a federal privacy law that protects your personal health information and medical records.
  • In-network providers: In-network providers include doctors, health care providers, pharmacies and hospitals where you pay less out-of-pocket. Out-of-network providers are not preferred providers for your insurance plan, so you may end up paying more or be unable to have their services covered by your insurance.
  • Out-of-pocket maximum: This is the most you will pay for health services. Once you reach your out-of-pocket maximum, your insurance will pay all your medical costs.
  • Premium: The premium is what you pay monthly for health insurance. You may or may not see this bill, depending on your insurance type.
  • Prior authorization: Some health insurance companies must approve certain medical services before you use them.
  • Prescription drug coverage: This is what your health insurance will pay for prescription medications.
  • Specialist: A specialist is a doctor that specializes in a specific area of medicine. For instance, a cardiologist specializes in the heart.

How Insurance Works at the Doctor’s Office

Ensure you know your plan’s limitations and coverages before using it at the doctor’s office. Most plans require you to use in-network providers, so you will want to do that to receive the most benefit. You can contact your insurance company for a list of in-network providers or search online using their website.

At your first doctor visit with a new provider, you will need to know your social security number and bring your insurance card and driver’s license or identification card. The doctor or hospital will add the information to your file and bill your insurance company for your medical services before billing you.

Depending on your insurance plan, you may have to pay a copay the day you receive services. This depends on the type of insurance you have and the specifics of your policy. The deductible, coinsurance and any other amounts are billed to you after your insurance pays its portion.

Learn More at Foot & Ankle Surgical Associates

Foot & Ankle Surgical Associates can diagnose and treat many foot and ankle problems. Whether you suffer from something mild like an ingrown toenail or something severe like a broken bone, we can help you recover so you can get back to doing what you love.

We offer many podiatry services, including surgery, orthotics and physical therapy. We can treat heel pain, foot pain and ankle pain. To schedule an appointment, call us today at 360-754-3338 or fill out a contact form. You can also browse other important patient information and guides to feel more prepared to take charge of your health.

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