Fully understanding your healthcare policy can be a daunting task for many individuals. What is co-insurance? Do I need a prior authorization? We recently sat down with our healthcare experts to have them answer some of the most commonly asked healthcare related questions from group members.
1) Do I need authorization from my insurance for all procedures?
No, you do not always need authorization. It is best practice however to check with your provider as to which types of procedures will require authorization.
2) What is the difference between HMO and PPO?
HMO’s tend to be more affordable, but you’ll usually get less coverage and more restrictions. They also require that the member utilize providers that are in the managed care network.
PPO’s are more flexible and provide greater coverage, but come with a higher price tag and in many cases, a deductible. A plus side is that PPO’s offer both in and out of network benefits, so you have more choices as to which doctor or specialist you can see.
3) Do I need a referral to see a specialist?
Typically you do not. The exception to this is if the plan requires a gatekeeper to manage the overall care of the member. A gatekeeper is a physician, typically a primary care physician, who is responsible for determining a patient’s primary services and coordinating the care so that appropriate services are given.
4) What is the maximum out of pocket payment if I go to the hospital?
Maximum out of pocket thresholds vary from carrier to carrier. The maximum limit after the deductible and co-insurance is typically $3000-$6,000 in network.
5) What is co-insurance?
Co-insurance is the percent that a plan will pay after the deductible has been satisfied.
6) Do I have to pay a deductible if I go to the doctor?
No, you will just need to pay the co-pay. Co-pays will vary based on your plan. The exception to this rule is if you have a Health Savings Account (HSA) compatible plan.
7) What is the difference between name brand and generic medication?
Generic versions of medications are allowed to be produced once the patent on the name brand drug has expired. Generic medications have the same active ingredient as the name brand, but use different binders which may result in them varying in size, shape, and color.
8) When am I eligible for Medicare?
U.S. residents are eligible for Medicare when they reach 65 years of age. There are special circumstances where individuals with disabilities are able to obtain Medicare before the age of 65. More information about these circumstances is available here.
9) How long can I continue COBRA?
If you have a qualifying event, you can continue coverage for 18 months. Qualifying events are events that cause an individual to lose his or her group health coverage. If the event is divorce or death, coverage can be continued for 36 months.
If you have any questions about healthcare coverage, our experts are ready to help you.
Sources: dol.gov “FAQs about COBRA Continuation Health Coverage“
