Understanding & Using Your Coverage
Get Covered Illinois can help you understand how much your coverage costs, what services are available, and how to use your coverage. This includes understanding terms like deductible or coinsurance as well as being able to calculate the costs of using your plan.
- 1. What kinds of payments will I make when using my plan?
- 2. Does the deductible apply to all of the health care services covered by my plan?
- 3. What is an out-of-pocket maximum?
- 4. What is a provider network?
- 5. How do I ensure that my prescription medicines are covered?
- 6. How do I get my prescriptions?
- 7. How do I find a doctor?
- 8. When should I visit my doctor?
- 9. What do I need to do to schedule and prepare for a doctor’s appointment?
- 10. Is it true that preventive care services are covered at no cost?
- 11. How can I use preventive care to stay healthy?
Premium payments are what you pay to ensure you are continually covered by your health insurance plan. This is your monthly bill that is paid directly to the insurance company for your plan, even if you don’t get medical services. Premiums can be paid different ways, including paying online with a credit card or through a bank account, or by mailing a check.
A deductible is the amount you owe for health care services that your health insurance plan covers before your health plan begins to pay for most services. After you have met your deductible, you may still have to pay for part of the health services covered by your plan, usually in the form of copays and coinsurance. For example, if the deductible for your plan is $500, once you have paid $500 for health services you need, your health insurance will begin to pay for covered health services. Your monthly premium (and possibly other charges) are not counted toward meeting your deductible.
Coinsurance is a type of cost-sharing where you pay a percentage of the total price for a covered health care service and your insurer pays the rest. For example, a coinsurance plan of 80/20 means that your health insurance company will pay for 80% of the cost for a service, while you are only responsible for paying the remaining 20%.
Copays, short for copayments, are fixed amounts you pay for health care services covered by your plan. These will include doctor’s visits, visits to a specialist, screenings, or filling prescriptions. Copay prices are often listed on your insurance card. If your copay is not on your card, you can call your insurance company to find out what it is.
Out-of-pocket costs are your medical care expenses that aren’t covered or reimbursed by health insurance. These include deductibles, coinsurance, and copays for covered health care services plus all costs for services that are not covered.
Here is an example to help you understand when you might use each of the above terms:
Maria has a plan with a $150 deductible with a coinsurance of 80/20. Her plan year starts in January with the deductible intact. That month, she falls off her bike and hurts her ankle, so she goes to urgent care to be examined. The urgent care visit costs $150. Because she hasn’t reached her deductible yet, she pays $150 out of pocket.
The urgent care doctor says Maria needs to use crutches until her ankle heals. The crutches cost $100. Now that she’s met her deductible, she pays just 20 percent coinsurance ($20) for the crutches, and her health insurance company will pay the other 80% ($80).
Maria’s ankle is hurting a lot, so her doctor prescribes her pain medication. Maria checks the list of prescription drugs that are covered by her insurance plan (also known as a formulary) and finds that there is a fixed $10 copay for this kind of medicine, so at the pharmacy she pays $10 to pick it up.
The deductible may not apply to all health care services. If the deductible does not apply to a covered service in your plan, your plan will cover it before you meet your deductible. For example, your plan may pay for the cost of recommended preventive services even if you have not met your deductible.
The out-of-pocket maximum is the most you will have to pay for covered medical expenses in a plan year, before your insurance plan begins to pay 100 percent of covered medical expenses. That amount includes your deductible and coinsurance. However, your premium payment does not contribute to out-of-pocket costs, so you will still need to pay your premium even if your out-of-pocket maximum is reached.
A provider network is a specific set of doctors, nurses, other health care providers, and hospitals that your health plan covers. These providers are called network providers or in-network providers; those not covered by your health plan are called out-of-network providers. When a provider is in-network, it means that they have agreed to provide benefits or services to the plan’s members at prices that the provider and plan agreed on.
You should always try to find in-network providers when seeking care to help keep your costs lower. To determine if your doctor is in-network, visit your health plan’s website and check the plan’s provider directory. You can also call your insurer or doctor’s office to find out.
All health insurance plans sold on the Marketplace are required to have provider networks with enough providers to help ensure that their plan members can access plan services without unreasonable delay.
To find out if your new health plan will cover your prescriptions, view your insurer’s formulary. You should know:
- The medicine’s exact name
- The dose you take
- How may pills your doctor prescribes
If your prescription is not covered, you can:
- Talk to your doctor about options
- Ask about the possibility for a one-time refill
- Ask if your health plan will cover a drug if there is a health need.
If you need prescription medicine, your doctor will fill out a prescription and give it to you, or send it to your local pharmacy. If the doctor gives you the prescription, you can have the prescription filled at a pharmacy that is in your provider network.
Either call the pharmacy or your health insurance company to determine if the pharmacy is in-network.
Prescriptions often can be filled through different pharmacies, such as:
- Local drugstores and supermarkets
- CVS Pharmacies
- Walgreens Pharmacies
- Walmart Pharma
- Target Pharmacy
Choosing the right doctor is an important step in getting the most out of your health insurance.
First, find the names of doctors near you who are in your insurance plan’s network so you will have lower out-of-pocket costs. You can call your insurance provider, search their website or ask family members, friends, or colleagues for referrals. After finding a few doctors in your network, call their offices to ask if they are accepting new patients, where their offices are located, what their hours of operation are, and if they speak your preferred language. This can narrow your search.
Once you have determined that your doctor is in-network and covered by your health insurance, you can begin scheduling appointments. In order to stay healthy annual wellness visits are recommended and covered under all plans in your network.
Here are some questions you may want to ask during your visit:
- How can I improve my health?
- What do I need to do?
- Why is it important for me to do this?
- Do I need to schedule a follow up appointment?
You should also feel free to take notes and write down information during a doctor’s visit. You have a right to understand what the doctor recommends. If you don’t understand, you should ask your doctor to repeat it or explain it differently.
When you call to make your doctor’s appointment, have your insurance card available and be prepared to tell the receptionist:
- Your name, and if you are a new patient
- Why you want to see the doctor (for an annual exam or for a specific concern such as allergies, headaches, etc.)
- The name of the doctor you want to see
- Your health insurance plan and confirm the doctor is in network with your insurance plan
- If you have specific requests such as language requirements
- The days and times that work best for you
To prepare for your appointment, write down your family’s medical history (any conditions that you or a family member have had), as well as any medications you are currently taking or are allergic to.
Also, write down any questions you have for the doctor.
Yes, Affordable Care Act (ACA) compliant health plans are required to cover preventive care services at no cost to you. Preventive care services are routine health care services that include screenings, check-ups and patient counseling to prevent illness, disease or other health problems. If you visit a doctor in your network, you will not have to pay a copay or coinsurance for doctor office visits to get preventive care.
Check with your insurance company to ensure that you fully understand the services available through your plan. You also can talk to your doctor about the recommended preventive care services for you.
Examples of preventive care services include:
- Immunizations and screenings
- Pregnancy and newborn care
- Diabetes prevention and treatment
- Managing heart disease
- Living with and reducing hypertensions
- Managing obesity
- Quitting smoking