How Does Health Insurance Work? 

Navigating the world of health insurance can be complex, but we're here to help you understand the basics. Health insurance is a financial arrangement between individuals and insurance providers to ensure access to necessary healthcare services. Learn more about how health insurance works and how PlushCare works with your insurance coverage. 

What is Health Insurance? 

Health insurance essentially acts as a safety net, providing financial protection against potentially high costs of medical care. When you enroll in a health insurance plan, you enter into an agreement with the insurance company. The insurance company, in turn, commits to covering a significant portion of your healthcare expenses.   During open enrollment, you can select or change your health insurance plan. It's crucial to reassess your healthcare needs and ensure your chosen plan aligns with your requirements. Learn more about open enrollment.   Health insurance operates on the cost-sharing principle, where you and your insurance provider contribute to covering healthcare expenses. Let's dive deeper into the key concepts of health insurance and explore how cost-sharing plays a vital role. 

What is Cost Sharing in Health Insurance? 

Cost sharing is the financial partnership between you, the patient, and your insurance plan, extending beyond the regular monthly premium. This collaborative approach comes in diverse forms of payment: 

• Deductible refers to the amount you pay for covered healthcare services before your insurance kicks in. Your deductible typically resets at the beginning of each year. 

• Copayments (copays) refer to fixed amounts you pay for specific services or prescriptions.  

• Coinsurance refers to a percentage of healthcare costs you pay after meeting your deductible. 

Learn more about the difference between copay vs. coinsurance.  

  Empower yourself with the following tips to effectively manage cost sharing and navigate your healthcare expenses with confidence: 

• Know your plan: Understand your individual deductibles, copays, and coinsurance. Every insurance plan is different! Keep this information handy. 

• Plan for deductibles: If you have a high deductible, consider setting aside funds in a health savings account (HSA) or flexible spending account (FSA) to help cover costs. 

• Ask questions: If you’re uncertain about coverage or costs, contact us or your insurance provider for clarification. 

What is a Deductible, and How Does It Affect My Healthcare Costs?  

A deductible represents the initial amount you contribute towards your healthcare expenses before your insurance plan begins to cover them. It's like a threshold; once you spend this amount, your insurance takes over, paying a portion or all of the costs for covered services. Your deductible typically resets at the beginning of each calendar year.   Whether you have a deductible depends on your health insurance plan type. Distinct plan types with deductibles include: 

• High-deductible health plans (HDHPs): often feature higher deductibles, frequently associated with health savings accounts (HSAs). 

• Preferred provider organizations (PPOs) and health maintenance organizations (HMOs): PPOs typically involve deductibles, while HMOs may or may not, especially for in-network services. Learn more about the difference between HMOs and PPOs. 

• Point of service (POS) plans: These plans frequently have deductibles, particularly for out-of-network care. 

There are a couple of ways to identify your deductible: 

• Insurance card: Check your insurance card and look for terms like "individual deductible" or "family deductible." 

• Plan type: The type of plan (e.g., PPO, HMO) provides insights into the likelihood of having a deductible. Familiarize yourself with these indicators to better understand your healthcare coverage. 

• Policy documents: More detailed information is usually available in your policy documentation. 

Before your deductible is met, you're responsible for healthcare costs up to the deductible amount. After your deductible is met, your insurance coverage kicks in, often leaving you with a copay or coinsurance for covered services. Look for deductible information on your insurance card or policy documents. Contact your insurance if it's unclear or if you still have questions. 

How Do I Confirm My Provider is In-Network? 

Ensuring your healthcare provider is in-network is crucial for maximizing your insurance benefits and minimizing out-of-pocket costs. Here's how you can verify if your provider is in-network:  

• Check your insurance provider's website: Most insurance companies have online directories that list in-network healthcare providers. Visit your insurance provider's website and use their search tool to find your doctor or healthcare facility. 

• Call your insurance company: Contact your insurance company's customer service to confirm the in-network status of your provider. Make sure to provide specific details, such as the doctor's name, location, and the type of service you're seeking. 

• Consult your provider's office: You can also directly inquire with your healthcare provider's office. They often have up-to-date information about their network status and can guide you on how to navigate insurance coverage. 

What to Expect When Paying with Insurance 

Understanding the process of paying with insurance can help alleviate confusion. Here's a step-by-step guide: 

1. Booking an appointment 

When you book an appointment with insurance, your upfront cost is an estimate of what you owe based on your insurance plan. Factors like your in-network policy and deductible can influence your upfront estimated cost. 

2. Submitting an insurance claim 

After your visit, your doctor and our billing team will finalize your appointment details and promptly submit a claim to your insurance with details about the services provided during your visit. 

3. Insurance claim processing 

Your insurance company will review the submitted claim, assess the services provided during your appointment, and determine how much of the cost they will cover based on your plan. This can take a few weeks. 

4. Insurance claim response 

Once they reach a determination, your insurance company will mail you an Explanation of Benefits (EOB) document that breaks down your coverage details and outlines any remaining balance you may owe due to your visit.  Your insurance will pay us directly for the services covered by your plan. 

5. Your outstanding bill 

If your insurance indicates that you owe more for the visit than was initially collected when you booked the appointment, you’ll receive a patient statement via email, providing a detailed overview of the remaining balance you owe. 

You can settle your balance conveniently online using various payment methods, including credit cards, debit cards, health savings accounts (HSA), or flexible spending accounts (FSA). To use HSA and FSA cards, you can pay directly by adding your card but will need to submit a receipt for reimbursement. Some valuable tips to ensure a smooth transaction include: 

• Keep your information updated: Ensure your insurance and contact details are up-to-date in your profile to avoid any delays or discrepancies. 

• Know your plan: Familiarize yourself with important details such as your deductible, copay, and coinsurance to anticipate potential out-of-pocket costs. If you have any questions about your plan, call the number on the back of your insurance card before using your insurance, to avoid any surprises. 

• Review EOB carefully: Thoroughly check your explanation of benefits (EOB) for accuracy, and don't hesitate to reach out to your insurance company for clarification if needed. 

If you have any questions or concerns regarding your bill, our dedicated team is here to provide guidance and support. Feel free to contact us to confidently and easily navigate your post-visit financial journey. 

Why Am I Receiving a Bill? 

When you book an appointment, we gather an upfront estimated cost based on expected services and the information you submitted about your insurance plan. However, the final cost may differ based on your insurance's response to the claim we submit after your visit.  Several factors could impact your visit cost: 

• Deductibles: If your insurance has a deductible, and it's not met, you're responsible for this portion of the cost. This applies to all visits, whether they are in physical clinics or done virtually. 

• Coinsurance and copayments: Your plan may include coinsurance or copayments besides a deductible. 

• Out-of-pocket maximum: This is the maximum amount you pay during a policy period before your insurance covers 100% of the allowed amount for covered services. 

• Non-covered services and insurance denials: Services not covered or denied claims (due to lack of prior authorization or medical coding discrepancies) may incur costs for which you're responsible. 

• Plan limits: Your insurance might limit the number or type of covered visits or procedures. Charges beyond these limits will be billed to you. 

• Out-of-network services: If you receive services from providers not in your insurance network, the cost may be higher, and your insurance may cover less or none. 

 Please note that your outstanding balance is separate from any of the following costs: 

• Your monthly premium: this is what you pay your insurance plan for coverage on a monthly basis. 

• Your PlushCare membership fee: this is the monthly fee to be a PlushCare member, which gives you access to our platform of doctors, our patient support team, and the PlushCare app. This is separate from any doctor's visit fees or costs for medication. 

Some tips to navigate billing and insurance include: 

• Stay informed: Understanding your insurance plan details (deductibles, copays, coverage limits) helps anticipate potential charges. 

• Seek clarifications: If you have questions about your bill or notice differences between the estimated and final charges, don't hesitate to reach out. We're here to assist in making sense of your billing and insurance. 

What is an EOB? Is It a Bill? 

An EOB is not a bill. It is an important document indicating your insurance coverage. While not a bill, the explanation of benefits (EOB) may signal an additional amount owed beyond your initial payment. Check your email for a bill from us outlining the remaining balance, if any, and conveniently settle it through our online payment portal. Here's what to look for:  

1. Patient information: Ensure your name and policy number are accurate to facilitate smooth processing. 

2. Provider information: This section provides details about our practice and the healthcare provider involved. 

3. Claim number: This unique identifier is assigned to your medical claim, which you can reference for any questions. 

4. Date of service: This identifies the date when you received the medical service. 

5. Service description: This offers a summarized breakdown of the services provided, including visits, lab tests, imaging, and more. Certain services may include facility fees, which can be covered if you choose a preferred network or facility through your insurance provider. 

6. Charges: This is the total cost billed for the various services rendered. 

7. Discounts: Some plans entail negotiated discounts between the care provider and the insurance carrier. 

8. Covered amount: This specifies the portion of the bill your insurance commits to pay, aligned with your plan's coverage. 

9. Deductible, copay, coinsurance: This shows the extent of your responsibility for the bill, considering your plan's deductible, copay, or coinsurance. 

10. Paid to provider: This reveals the amount paid by your insurance directly to us for the provided services. 

11. What you owe: This is one of the most important segments, explaining the out-of-pocket expenses, which may comprise deductibles, coinsurance, or non-covered charges. 

12. Benefits explanation: This elaborates on why certain charges were covered or not covered by your insurance. 

13. Appeal information: In case of a disagreement with the claim processing, this section provides insights into the appeal process. 

How Do I Find Out if My Insurance Company Paid a Claim? 

To check if your insurance company has paid a claim, follow these steps:  

• Review your explanation of benefits (EOB): The EOB provides a comprehensive breakdown of the services covered, the amount your insurance will pay, and your responsibility for any remaining balance. 

• Check your insurance portal or app: Many insurance companies offer online portals or mobile apps where you can track the status of your claims. Log in to your account to view recent transactions and payments. 

• Contact your insurance company: If you're unsure or need clarification, don't hesitate to reach out to your insurance company's customer service. They can provide real-time information on the status of your claims and address any questions you may have. 

By staying informed about your provider's network status, understanding the claim processing timeline, and actively checking the status of your claims, you empower yourself to navigate the complexities of health insurance more effectively. If you have further inquiries or need assistance, feel free to reach out to us. We're here to guide you through every step of your healthcare journey.  

What if I Have Questions About My Bill? 

If you have any billing questions, please feel free to contact us at (855) 559-2285. We can explain how to pay, help you understand why you are receiving a bill, and answer any other concerns you may have. For specific questions about coverage or denials, contacting your insurance provider can offer clarity. You can find the number to call your insurance on the back of your insurance card. 

What to Know About Primary and Secondary Insurance Coverage 

If you have your own insurance or are covered under your spouse's policy, it's crucial to know about "primary insurance." This is the main insurance that takes care of the initial expenses. If there's a secondary insurance, it comes into play after the primary insurance has contributed its share. Rules for coordinating benefits ensure a smooth interaction between multiple policies, preventing overpayment. In navigating the complexities of health insurance, we aim to empower you with the knowledge and support needed for a seamless healthcare experience. Remember, understanding your insurance plan, staying informed about denial reasons, and taking proactive steps in managing your coverage can make a significant difference. Whether it's reviewing your explanation of benefits (EOB) or updating your insurance information, we're here to assist you every step of the way. Your health and well-being are our priorities, and we're committed to ensuring that your journey with us is medically appropriate, financially transparent, and stress-free. If you have any further questions or need assistance, don't hesitate to reach out – we're here to help. 

Read More About Health Insurance 

• How to Avoid a Surprise Medical Bill 

• How PlushCare Works 

Sources

1. Healthcare.gov: "HealthCare.gov." Accessed on January 22, 2024, at https://www.healthcare.gov/. 

2. USA.gov - Health Insurance: "Health Insurance." Accessed on January 22, 2024, at https://www.usa.gov/health-insurance. 

3. CMS (Centers for Medicare & Medicaid Services): "Explanation of Benefits." Accessed on January 22, 2024, at https://www.cms.gov/medical-bill-rights/help/guides/explanation-of-benefits. 

4. Healthcare.gov - Glossary: "Deductible." Accessed on January 22, 2024, at https://www.healthcare.gov/glossary/deductible/. 

5. Healthinsurance.org - Glossary: "Health Insurance." Accessed on January 22, 2024, at https://www.healthinsurance.org/glossary/health-insurance/.