Understanding health insurance coverage to maximize your care
When people find themselves in the middle of a personal or family health issue, they can easily become overwhelmed by new realities, complexities and lifestyle changes. By eliminating the “unknowns” about the administration and payment of their care, patients can be more mentally, emotionally and actively available to participate in the delivery and management of their care. Being in the proper frame of mind to focus on their course of medical treatment is one of the most important ways a patient can help position themselves for the best possible outcomes.
Understanding how your health insurance works is a vital component of being prepared for care. Follow these simple guidelines to fully utilize your benefits, and focus your mind on being an involved patient or patient’s advocate:
1. Understand the specific “in-network” and “out-of-network” coverage benefits of your health plan. This can be crucial when selecting a provider. In-network benefits leave members with a much smaller out-of-pocket responsibility to pay than out-of-network. Healthcare consumers need to consider the qualifications and reputations of their care providers and facilities, and factor in any potential out-of-pocket costs that may be incurred. A financial surprise that causes undue stress should always be avoided as it can complicate care.
2. HMOs—Know before you go. If you have HMO coverage, you may be required to see your Primary Care Provider (PCP) before seeing a specialist. Make sure you receive prior authorization from your PCP if required otherwise some benefits may not be covered.
3. Know Your Out-Of-Pocket Balance. Contact your insurance company’s customer service or check online to find out what your out-of-pocket limit is as well as your remaining out-of-pocket balance. You will not receive maximum benefits until your deductible, out-of-pocket maximum, and any other benefit plan requirements are met.
4. Notify Your Insurance Company: If admitted to a hospital, notify your insurance company to register or pre-authorize for services. If it is an emergency, go to the emergency room first to get treated and then contact your insurance company as soon as possible, to confirm which procedures and/or stays are allowed for your situation.
5. When possible, request generic prescriptions to help save on your out of pocket prescription drug costs.
6. If you have Medicare and/or a Medicare supplement product, make sure your provider contacts Medicare and your insurance company first to verify if the treatment, device, or admittance to a hospital/care facility are covered. For further information on Medicare, please go to the Medicare.gov website, use our AskBlue Medicare tool, or see a listing of participating Blue Cross and Blue Shield Medicare Advantage and prescription drug plans.
Being well-informed about how your health insurance works can help patients and their caregivers become more engaged with their own treatment, and increase the quality of their own care. For more tips on how to better understand your Blue Cross and Blue Shield coverage, read our Frequently Asked Questions.