Benefits are the services that get paid for by your health insurance company. All health insurance plans cover essential health benefits, which include emergency care, mental health and substance abuse, maternity and newborn care, prescription drugs, lab tests, preventive services, and pediatric services.
Making healthy decisions and taking control of your nutrition, exercise, relationships and lifestyle can lead to a better quality of life. Most preventive care benefits are no-cost services to help you stay healthy and cover things like health screenings, weight management counseling, immunizations, and programs to help you quit smoking. Additional programs may include online health assessment tools, fitness programs, and low back pain support.
The prescription drug benefit is the most frequently used benefit of a health plan. The cost of drugs depends on the tier or level that the drug is placed in by the health insurance company.
$ Tier One drugs are typically generics and cost the least.
$$ Tier Two drugs are brand drugs that have unique, significant clinical advantages and offer overall greater value over other products in the same drug class.
$$$ Tier Three drugs are all other brand drugs, including new brand drugs and those that have generic equivalents. Tier Three drugs typically cost the most.
Specialty drugs for conditions like multiple sclerosis, rheumatoid arthritis, growth hormone deficiency, and other conditions that are difficult to treat with traditional therapies are usually handled by specialty pharmacies.
Your primary care physician (PCP) is the main point of contact in your care. Think of them as the quarterback of your health care team. Your PCP is responsible for coordinating care so you can get the care you need with fewer trips to the hospital or doctor’s office.
If you have a more serious injury or illness your PCP may suggest that you need to see a specialist. In general, you will pay more for specialty care. Some plans won't pay for you to see a specialist unless your primary care physician thinks it is necessary.
If you have an injury or illness that can’t wait for a visit to your doctor’s office or if your doctor’s office is closed, there are Urgent Care centers, Telemedicine (visits by phone or internet), and Emergency rooms. These are not the place for routine care.
Your teeth and eyesight are important parts of your overall health. Some plans include dental and vision coverage, while others require you to purchase it separately.
People often think that networks are based on where you live or where your provider is located. "Network" actually refers to providers (doctors, hospitals, pharmacies) your insurer has a relationship with. In-network providers often cost less. You can still choose an Out-of-network provider, but you may wind up paying more. For your convenience, we have compiled examples of Out-of-Network Costs on our website. You may also visit Fair Health’s website (www.fairhealthconsumer.org) to estimate potential out-of-network out-of-pocket expenses. Please note: Medicare cost information may be found at CMS.gov fee schedule search tool.
Copays, Deductibles, Coinsurance
Every plan involves cost sharing—the amount you pay when you get a service and the amount your insurance company pays. Every plan also has an out-of-pocket maximum which is the most you would ever have to pay for services in a plan year. If your out-of-pocket maximum is reached, your insurance company picks up the balance of the allowed expenses as long as you continue to pay your monthly premium.
Some plans have a fixed amount you pay each time you use a medical service, like a doctor’s visit or prescription refill. Example: If your plan’s coverage includes a $20 copay for a Primary Care Provider (PCP), you pay $20 for each visit to your PCP and your insurance company pays the balance.
Some plans have an amount of money you have to pay before the health insurance company will make any payment toward your health care services. Example: If you have a $500 deductible, you pay 100% of your first $500 in medical bills before your insurance pays anything. After you reach your deductible amount, you may pay a portion of your health care costs and your health insurance company will pay the rest.
Coinsurance is similar to a copay, but instead of a fixed-dollar amount, you pay a percentage of the total bill. Example: If your coinsurance on a $100 bill is 15%, that means you pay $15 and your insurance company pays the rest, or $85.
Health Savings Accounts
An HSA is a tax-free funding account owned by you that helps you pay for qualified medical expenses such as lab fees, prescription drugs, contact lenses, chiropractor visits and more. HSAs can only be used with certain High Deductible Health Plans (HDHP).
This is a type of insurance plan that has a lower monthly premium than other insurance plans but you will pay more toward health care services before the insurance company will begin making payments.
Flexible Spending Accounts
A Flexible Spending Account (FSA) offers a smart, simple way to set aside money tax free to cover the everyday expenses you know you'll have in the coming year. You can use it to pay for eligible non-covered medical or dental expenses, child care, and even dependent adult care costs.How to save with an FSA
When you receive medical care or need a prescription, your provider or pharmacy sends a claim to the insurance company. Depending on your plan benefits, how much the insurance company will pay and how much you will pay is determined through the claims process. A monthly explanation of benefits (EOB) is sent to you so you can see the services and costs of those services.
Whenever a claim is approved or denied, an explanation of benefits (EOB) form is sent by the insurance company. The EOB will explain why a decision was made and will include information on how to contact the insurer in case you have any questions. In addition, a monthly health statement clearly explains how much has been paid to your providers.