Medical insurance is a legal entitlement to help pay for a wide range of health care services. It’s offered through private companies in a variety of ways, such as employer-sponsored plans and individual or family coverage, and it’s also available through government programs like Medicare, Medicaid and the Children’s Health Insurance Program. Each type of plan has its own benefits and costs, but all provide the same basic rights and protections.
Whether you’re enrolled in a traditional plan, an HMO or an EPO, your plan must cover essential health benefits. These include preventive care visits, vaccines and yearly bloodwork at no extra cost to you. Your plan must also allow you to change doctors if you’re not satisfied, and offer interpreters if you don’t speak English.
There are different types of health insurance plans, which differ in the way they cover hospital, medical and prescription drug costs. Each type has its own deductibles, copays and coinsurance. Most plans also have limits on the amount you’ll have to pay each year before the insurance company starts paying. These out-of-pocket maximums are usually capped at some level, so you will never have to pay more than this amount in any one benefit year.
Most traditional plans, such as HMOs and PPOs, require that you see in-network providers to avoid higher fees. They also often have “referral” requirements, requiring that you first get a referral from your doctor before seeing certain specialists.
Some plans limit the number of times you can see an out-of-network provider in a calendar year, while others don’t. You may also find that some drugs aren’t covered by your plan if they’re not on a “formulary” list set by the insurance company. Some drugs require pre-approval, and some insurers may refuse to pay for name brand medications if there’s a generic equivalent or lower cost option available.
All insurance policies have a contract between the insurer and the insured, and a set of rules and regulations. You can find this information in your health insurance ID card, in your “Evidence of Coverage” booklet or your “member contract.”
If you have a problem with your insurance policy, try to resolve it directly with your insurer. You may call the customer service department or visit a local office to talk with a representative. If that doesn’t work, you can file a grievance or appeal. Generally, your insurance company must respond to any request for a review or appeal within 30 days. If your problem is urgent, you may ask for an expedited review or appeal. If you’re not satisfied with the outcome, you can file a complaint with your state’s insurance department or a federal agency.