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Know your Health Insurance! |
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Why Buy Health Insurance? |
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Medicare Info Center |
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The Six C's of Insurance
Having good health insurance is important but understanding or
choosing your health insurance is not easy. This page
gives you information and lists questions you
can ask about your health insurance.
1. Coverage
2. Co-pays
3. Claim Payment
4. Conditions That Affect Payment
5. Caps on Benefits
6. Cost of Insurance Premiums
1. Coverage:
Do the services cov-ered match the services you need?
Will the insurance provide theneeded drugs and equipment? Are there any exclusions?
2. Co-pays:
Few health insurance plans cover every expense. Out-of-pocket expenses are what you pay.
They are called co-pays and deductibles. It is important to find out what these will be for care.
Is your care team part of the insurance plan’s network? If your care team is outside the plan’s network,
ask about the yearly deductible amount and any charges you must pay beyond your normal co-pay to goto your doctor.
What will insurance pay after you meet the deductible? Also,find out your prescription drug co-pay.
With some insurance, you pay for the cost of the drug first and then fill out the paper work before insurance will
pay you back for the drug. With other insurance,you pay a percentage of the drug’s cost. You may not be able to
afford the drugs withthese plans. (See Table 1.) Usually, there is a lower co-pay for a generic prescription drug,
and a higher co-pay for a brand prescription drug. Know which brand drugs are covered by your insurance and what
your co-pay is.
3. Claim Payment:
Find out what you have to do before your insurance will pay the medical bill.
Some insurance will not pay the bill until you fill out a form. With other insurance, you pay the bill first and
then fill out a form before the insurance company pays you back.
4. Conditions That Affect Payment:
Do you need to call the insurance company to get prior authorization or approval before getting certain prescription
drugs, tests, or before being admitted to the hospital? Check to see if the health insurance company has a set time
frame to submit a claim or paperwork after services have been provided. Some insurance will not pay for services if a
claim has not been filed within a certain time period, such as 90 days or six months. Check the insurance coverage for
pre-existing conditions. Does your insurance plan consider your diagnosis as a pre-existing condition?
5. Caps on Benefits:
Many health insurance plans will have dollar limits on the amount to be paid for medical equipment,
physical therapy, or prescription drugs. Because some diseases requires a lifetime of expensive health care, see if the insurance
plan has a yearly or life time cap on the benefits that they will pay.
6. Cost of Insurance Premiums:
Be careful when changing to insurance with a lower premium. The insurance may have higher co-pays and deductibles. You could end
up paying much more out of your own pocket in the long run. For example, insurance with a lower premium may only pay 50
percent of your prescription drugs. Think about what it would cost you if you had to pay for half of the total cost of
your prescription drugs for one month. The better option maybe to pay a slightly higher monthly premium for insurance
that pays 80-100 percent of your prescription drug costs and/or one that requires a small co-pay.
Source: The Cystic Fibrosis Foundation
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