Enrolling in health insurance can be hard, but what might be even harder is understanding your coverage. It’s not really something taught in school, but it’s something that we can all benefit from knowing about.
Some Americans may be foregoing medical care because they’re unsure of what’s covered by their health insurance. A 2019 Policygenius survey found more than one in four people said uncertainty over their coverage had led them to avoid treatment. Survey respondents also had trouble defining basic health insurance terms like copay, deductible and premium.
When it comes to many things in life, knowledge is power. We answer seven health insurance questions you may be asking.
What is the difference between deductibles, copays and coinsurance?
Deductibles, copays and coinsurance are all medical charges you must pay out of pocket, even if you have insurance.
Copayment: Or copay, is the flat (fixed) fee you pay for routine visits, such as to your primary care doctor, a specialist, the urgent care or pharmacy, and covers your portion of the visit or medication. Your copay applies even if you haven’t met your deductible yet.
Deductible: Is the amount you pay (out of your own pocket) each year before your health insurance plan starts to pay toward your care. In many cases your copay will not go toward your deductible.
Coinsurance: Is the percentage of costs you pay for covered services after you’ve met your deductible. Say you have an 80/20 plan: your insurance will cover 80% and you’ll be responsible for 20%.
Want to learn more about common health insurance terms? Check out the “Understanding Common Health Insurance Terms” article. It has a great breakdown of some common health insurance terms that you will frequently encounter.
When does open enrollment occur?
Open enrollment is a period of time each year when you can sign up for health insurance. The time of year can vary depending on the health care plan you choose. If you miss this window, however, typically you have to wait until the next enrollment period, unless you have a qualifying event.
- Medicare: Annual open enrollment runs between October to December, however there are additional enrollment periods for those with Medicaid, Medicare Advantage and Medgap policies.
- Employer-based: Open enrollment is typically set in the fall, so new coverage begins in the new year, but it can happen at any time of the year.
- Health Insurance Marketplace: This is a one-stop shop for those who wish to purchase affordable health care coverage. Typically, this occurs between November and December.
- Exceptions: Aside from these timeframes, you may be eligible if you fall under some of these extenuating circumstances:
- Lost your job
- Moved to a new area
- Aged out of your parent’s plan
- COBRA insurance expired
Will my insurance cover telemedicine/telehealth?
Until just recently, the government was very strict about which technology could be used for telehealth. That’s changed with the pandemic. While COVID-19 has quickly driven many of us to stay at home, policies around telehealth have had to be reimagined. Right now, many states have laws, known as parity laws, which require private insurers to reimburse health care providers for services delivered through telemedicine.
For the latest regarding telemedicine eligibility, visit your health insurance plan’s website to check recent updates or read this guide by the American Telemedicine Association regarding laws in your state.
Which wellness services are free of charge?
Federal law requires most health insurance plans to provide certain preventive services free of charge, such as vaccines and screenings, but plans could cover other wellness services too. Many employers offer workplace wellness initiatives, such as dietary counseling and on-site exercise programs. Even some universities are offering their students free wellness services. It’s worth looking into with your employer, school and insurance plan.
Will my health insurance cover COVID-19 testing and treatment?
Under the Families First Coronavirus Response Act, Medicare, Medicaid and private health insurance plans – including grandfathered plans – are required to pick up 100% of the cost of COVID-19 care, without any cost-sharing or prior-authorization requirements, for the duration of the emergency period. This includes any visits to the emergency room, urgent care or doctor’s office.
Insurers must also provide free antibody testing for COVID-19 patients under the Coronavirus Aid, Relief and Economic Security Act. For those who are uninsured, states are allowed to use their Medicaid programs to cover testing.
When it comes to treatment coverage, it can vary. Some insurers have waived copays, coinsurance and deductibles for in-network care, while others will cover patient cost-sharing out of network when no in-networks are available.
We encourage you to check with your health insurance plan regarding coverage. You can also check this health insurer list to find out what is covered.
Are routine preventive services like colonoscopies, mammograms and breastfeeding support covered by my insurance?
Under the Affordable Care Act, many routine preventative care services now must be fully covered by health insurance. That means you don’t have a copay, owe coinsurance or have to meet a deductible first. These may include breastfeeding support and counseling, immunizations, colorectal screenings and breast cancer genetic test counseling (BRCA).
Do I need a referral?
A referral is a pre-approval that certain health care plans require before you can seek treatment from providers other than your primary care provider. Health maintenance organizations (HMO) and point of sale (POS) plans require a referral from your primary care provider. Referrals are not required for a preferred provider organization (PPO) or an exclusive provider organization, but these plans tend to be more expensive than HMO plans.
Managing Your Health Care Costs
During this time of uncertainty, managing health care costs is more important than ever. As you look at finances, there are a couple options you may want to consider.
If you are signed up for a high-deductible health insurance plan (HDHP), you may be able to lower your out-of-pocket costs by funding a Health Savings Account (HSA). Here is how it works: When you fund an HSA, you set aside pre-tax dollars (up to $3,500 single, $7,000 family) to pay for qualified medical expenses, including deductibles, copays and coinsurance. By paying with pre-tax money, you are effectively lowering the amount you pay in health care costs. You can open an HSA even if your employer doesn’t offer one, as long as you have a qualifying health insurance plan and are not enrolled in Medicare. Any dollars left in the account at the end of the year can roll over and be used in the future.
Another way to save with pre-tax money is to enroll in a Flexible Spending Account (FSA). Your employer may offer an FSA as part of your benefits package. An FSA sets aside pre-tax dollars (up to $2,700) to pay for qualified medical expenses, similar to an HSA. However, an FSA does not require enrollment in a health insurance plan, and it is fully funded on day 1. The downside of an FSA is that if you do not spend all the money in the account by the end of the your plan year, you will lose it.
You may want to consult your financial advisor to see how either of these accounts may affect your bottom line.
When all is said and done, if in doubt about your health insurance coverage, don’t hesitate to contact a customer service representative with your health insurance plan to confirm your coverage and put your mind at ease. The phone number is often listed on the back of your insurance card. For a Banner Health provider near you, visit bannerhealth.com.