Insurance Coverage - Frequently Asked Questions
Q: Can services be covered until a decision is made for prior authorizations?
A: Generally health plans will not agree to cover services until the determination is made. If the case is critical, some plans will authorize retrospectively. However, you should not count on this.
Q: Can time frames for prior authorizations be accelerated to assure appropriate and timely care?
A: Acceleration of authorization depends upon the plan type and design. Each health plan should be able to supply you with policy information upon request.
Q: How do I find out if there are pre-existing condition clauses limiting my coverage?
A: Call the benefits number on the back of your insurance card or refer to the written Summary Plan Description (SPD).
Q: How do I find out what is covered under my plan?
A: Call the benefits number on the back of your insurance card or refer to your Summary Plan Description (SPD).
Q: How long are pre-existing conditions denied?
A: Pre-existing conditions are exclusions and are dependent on the health plan design. Refer to your benefit administrator or Summary Plan Description (SPD).
Q: What are "deductibles," "co-insurance" and "co-pays?" How do they differ?
A: Deductibles - Amounts required to be paid by the insured under a health insurance contract, before benefits become payable. They are usually expressed in terms of an "annual" amount.
Co-Insurance (coinsurance) - A cost-sharing requirement under a health insurance policy that provides that the insured will assume a portion of percentage of the costs of covered services. Health care cost which the covered person is responsible for paying, according to a fixed percentage or amount. A policy provision frequently found in major medical insurance policies under which the insured individual and the insurer share hospital and medical expenses according to a specified ratio. A type of cost sharing where the insured party and insurer share payment of the approved charge for covered services in a specified ratio after payment of the deductible. Under Medicare Part B, the beneficiary pays coinsurance of 20 percent of allowed charges. Many plans provider 100% insurance (no coinsurance) for preventive care or routine care provided "in network."
Co-Payment, Copayment, Copay - A cost-sharing arrangement in which the member pays a specified flat amount for a specific service (such as $10 for an office visit or $5 for each prescription drug). It does not vary with the cost of the service and is usually a flat sum amount such as $10 for every prescription or doctor visit, unlike co-insurance that is based on a percentage of the cost.
Q: What are "prior authorizations?" How are they handled?
A: Authorizations for treatment are sometimes required by your health plan prior to receiving certain healthcare services. In order to find out which services, if any, require a prior authorization, call the benefits number on the back of your insurance card or ask your employer for a copy of the Summary Plan Description (SPD).
Q: What if I don't agree with my insurance company's decision and services are denied?
A: Most plans have a review and/or appeals process. Call the benefits number listed on the back of your insurance card or refer to your Summary Plan Description (SPD) for process details and requirements.
Q: What is "in-network" and "out-of-network?"
A: A provider is considered "in-network" when the provider has an agreement with a health plan to accept health plan members at a previously agreed upon, usually discounted rate. A provider who does not have an agreement with your health plan to accept the health plan's members is considered "out-of-network."
Q: What is a provider and how do I know who my providers are?
A: A healthcare provider is anyone who supplies healthcare services. Each health plan may have different preferred providers. In order to find out which providers are covered at the highest benefit on your plan, call the benefit number listed on the back of your insurance card and request a list of network providers.
Q: What is an "out-of-pocket max?" What qualifies towards the out-of-pocket max?
A: The out-of-pocket max is the maximum amount that a beneficiary will pay in an annual period. After the out-of-pocket max is hit, the plan will pay 100% of covered expenses up to the policy limit. Refer to the Summary Plan Description (SPD) to find out which expense paid by the covered individual qualifies toward the out-of-pocket maximum and what that limit will be in a given year.
Q: What is the appropriate time frame for approvals?
A: Appropriate time frame for approvals is dependent on the service type, the individual's medical situation, and the health plan (usually no more than one to two business days). Refer to your Summary Plan Description (SPD) and/or when you call for a pre-authorization, ask for a time frame when you can expect an answer. Remember to get a contact name and phone number to ensure a prompt response.
Q: Who decides if services pertain to pre-existing conditions?
A: The health plan determines pre-existing condition exclusions and requirements. Generally, a medical director will be involved in this determination.