7 THINGS TO KNOW ABOUT YOUR INSURANCE COVERAGE
• After your new baby arrives you must notify your employer and your insurance company to add him/her to the policy. The insurance company DOES NOT automatically know that you had a baby. The baby is PRESUMED to be covered under the mother’s policy for 30 days, ONLY if you add the baby to your medical plan.
• Some Point of Service (POS) and all Health Maintenance Organization (HMO) plans require you to choose a Primary Care Physician (PCP). One of our doctors MUST be listed on the card in order for your insurance company to pay the claim!
• Most insurance policies now have a deductible and/or coinsurance, which may be in addition to your copay.
• In general, most policies now cover preventive health visits (check-ups) without a copay, coinsurance, or deductible. However, this does not mean that all services done at the health check are covered. Many insurance companies do not fully cover charges for additional services like hearing/vision screen and hemoglobin/cholesterol testing.
• If you want the physician to address any other significant concerns during the health check (like an ear infection, asthma, or ADHD), this will likely NOT be included as part of the health check. This means your insurance company will require you to cover the cost via copay, coinsurance, or deductible.
• Our doctors offer treatments or services that they feel are best for your child: services such as lab tests, treatments like ear wax removal, and prescription or referral to a specialist. This, unfortunately, might not be covered by these services. In order to avoid significant out of pocket costs, you should check to see if that service or physician is covered “in network” BEFORE you have the service. Most insurance companies will not go back and reconsider a charge if there was another option.
• Your insurance policy is a contract between you and the insurance company. As a courtesy, we will file the claim one time initially with the insurance information you provide at the visit. If the service is not covered, or you did not provide the current information, we are not responsible for refiling the claim and you may be responsible for the entire cost of the visit.
Coinsurance: The money you have to pay for health services after you have paid the deductible
Copayments: The fee paid for a doctor visit, hospital stay or other service
Deductible: The amount of money you pay before your insurance starts to pay
Eligible expense: A service or product recognized by the IRS that is purchased to help treat a medical condition or prevent a disease
Employee contribution: The money an employee pays to be covered by a health plan; also called “premium”
Flexible Spending Account (FSA): An employer sponsored account in which pre-tax funds are set aside from an employee’s paycheck each year. FSA funds can be used for eligible medical expenses, dependent care or commuter expenses, as determined by the IRS
Health Maintenance Organization (HMO): A kind of health insurance plan that usually requires members to receive services through doctors, labs, and hospitals that contract or work with the HMO
Health Reimbursement Account (HRA): Health care accounts that employers fund for covered workers or retired persons; IRS does not tax this money; also call Health Reimbursement Arrangements
Health Savings Account (HSA): Health care bank accounts that let people put money aside tax free to pay for medical, dental and vision costs; IRS limits who can open and put money into HSA; money in HSA stays in the account until it is used
Network provider: All the doctors, hospitals, nursing homes and laboratories that have contracts with an insurance company; also called “in-network” provider and “participating network” provider
Non-network provider: Doctors, hospitals, and other health care professionals who do not participate in our network and may provide services at a higher cost
Out-of-pocket maximum: The most you have to pay for health services; once paid, the insurance company pays 100 percent of eligible health care costs
Point-of-service (POS): A health benefit plan that allows the covered person to choose to receive service from a participating or non-participating physician or other health care provider, with different benefit levels associated with the use of participating physicians or other health care providers
Preferred Provider Organization (PPO): An organization where providers are under contract to provide care at a discounted or negotiated rate.