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Semelhante a From Coverage to Care insurance literacy
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From Coverage to Care insurance literacy
- 1. From Coverage to Care A Roadmap to Better Care And a Healthier You
- 3. Put Your Health First • Maintain a healthy lifestyle • Get your recommended health screenings and manage chronic conditions. • Keep all of your health information in one place. You may be able to receive an annual visit or some recommended preventive services for free like the flu vaccine, obesity screening and depression screening.
- 4. • Check with your insurance plan to see what services are covered. • Be familiar with your costs. • Know the explanation of some key health insurance words. . Understand Your Health Coverage
- 5. Key Health Insurance Words • Network • Deductible • Co-insurance • Copayment • Premium • Out of Pocket Maximum • Explanation of Benefits
- 6. Your Insurance Card or Other Document • Membership Package or Benefit Package • Insurance card or other document as Proof of Insurance • Prevent Health Care Fraud Don’t let anyone use your insurance card. Keep your personal information safe. Call your insurance company immediately if you lose your insurance card or suspect fraud.
- 7. Know Where to Go for Care • Private Medical Group • Your Community Care Clinic • VA Outpatient Clinic • Urgent Care/Walk In Clinic OR • Emergency Room » Need Help? » Call 9-1-1 if you have an emergency or life-threatening situation.
- 8. Choose the Right Provider • A Primary Care Provider for adults. • Your child or teenager’s provider may be called a Pediatrician. • If you’re elderly, your provider may be called a Geriatrician. • A Specialist will see you for certain services or to treat specific conditions.
- 9. Find a Provider • Identify providers in your network. • Ask Around. • Choose a Provider – Call the Provider’s Office. • Give Them a Try!
- 10. Make an Appointment • Demographic information • New or Established Patient • Reason for Appointment • Type of Insurance • Name of Provider
- 11. Be Prepared for Your Visit • Show up early for your appointment! • Check in with the front office staff. • Complete additional forms. • Read privacy policy. It is required by the law. If you need to change your appointment contact your provider’s office as soon as possible. Many providers charge a fee if you’re late, don’t show up,, or cancel less than 24 hours before it starts.
- 12. Follow UP the Next Step…. • Ask questions • Schedule future appointments, tests and procedures • Concerns between visits, call provider’s office
- 13. Insurance • Insurance Claim • Insurance Determination • Explanation of Benefits (EOB) • Appeals and Grievances
- 14. Thank You EnrollMO at PCRMC Phone: 573-458-3676 Email: enrollmo@pcrmc.com
Notas do Editor
- Use your health coverage when you are sick and when you are well to help you live a long and happy life. Put your health and well being first. Make time for physical activity, healthy eating, relaxation and sleep. Get preventive services that are right for you. Take an active role in your health. Preventive services include check-ups, and patient counseling that are used to prevent illnesses, disease, and other health problems, or to detect illness at an early stage when treatment is likely to work best. Have a provider who knows your health needs, whom you trust and you can work with. It is important to keep your medical information up to date and you may want to carry a copy with you for an emergency. Remember to protect your identity by keeping your personal information safe.
- Network is the facilities, providers, and suppliers your health insurer has contracted with to provide health care services. Contact insurance to find out if which provider is “in-network”. They may be called participating or preferred providers. If a provider is “out of network” it will cost you more to see them. Networks change . Deductible is the amount you owe for health care services your health plan covers before your health insurance or plan begins to pay. Co-insurance is your share of the costs of a covered health care service, calculate as a percent of the allowed amount for services. You pay the co-insurance plus any deductibles you owe. Copayment or copay is an amount you may be required to pay as your share of the cost for medical service or supply. A copay payment is a set amount rather than a percentage. Premium is the amount that must be paid for your health insurance or plan. Out of pocket maximum is the most you pay during a policy period(usually one year) before your health insurance or plan starts to pay 100%for covered essential health benefits. This includes deductibles, co-insurance, copayments, or similar charges and any other expenditure required of an individual for a qualified medical expense. 2014 individual $6350 and family $12,700
- Membership package/benefit package -with information about your coverage. This packet will contain information you will need to read and understand because you will need it when you see your provider or call your insurance. Some insurers want to email you the benefit package but will mail to you upon request. You may be required to pay your first months premium before this information is mailed. Contact your health plan if you didn’t receive an insurance card or packet. You will need your insurance card at each provider’s visit. Provider directories are available on line and may come with the benefit package. They change frequently. Fraud- If someone else uses your insurance card or member number to get prescription drugs or medical care, then they’re committing fraud. Help prevent health care fraud by protecting your insurance card.
- Although you can get health care at many different places, including the emergency department its best for you to get routine care and recommended preventive services from a primary care provider. There are some big differences between visits to your primary care dept. such as cost, time spent waiting for care, and follow up. Hand out table to see the many ways in which going to your primary care provider is different from going to the emergency department. Your Community Care Clinic- Sliding fee scale based on income and family size. The VA offers services to military veterans. Local clinic in St. James and hospitals in St. Louis and Columbia.
- If you’re an adult, your primary care provider may be called a family physician or doctor, internist, general practitioner, nurse practitioner, or physician’s assistant. Primary care providers work with patients every day to ensure they get the right preventive services, manage their chronic conditions and improve their health and well-being. Some places may offer services and supports that vary based on community needs. Primary care providers can link you to other types of providers if you need them. Specialists include: cardiologists, oncologists, psychologists, allergists, podiatrists, an orthopedists. (or get a specific instruction) from your primary care provider before you go to a specialist in order to have your health plan pay for your visit. , treatment plan, prescription drug, or durable medical equipment is medically necessary. This is also called prior authorization, prior approval or precertification
- Call your insurance company, look at their website, check your member handbook to find providers in your network who take your health coverage. Keep in mind you will pay more if you see a provider that isn’t in your network. If you already have a provider you like and want to keep working with, call their office and ask if they accept your coverage. Ask your friends or family if they have providers they like. Ask what kind of provider they are and what they like about them. Sometimes you can look up providers on the Internet to see what other people in the community say about them.
- Clearly state your name and date of birth Why you want to see provider The name of your insurance plan, Medicare, Chip or Medicaid Name of Provider you would like to see The days and times that work for you The name of your insurance plan, Medicare, Chip or Medicaid Name of Provider you would like to see The days and times that work for you You should also ask: If they can send you any forms you need to fill out before you arrive If you need to bring anything to the visit, like medical records or current medications What to do if you need to change or cancel appointment
- If this is your first visit to a new provider or you are using new health coverage, you will need to bring a few things with you. This will help your provider understand your health and lifestyle and help you work together to improve your health and well-being during your visit and after you leave. Insurance card or other documentation Photo identification(e.g., driver’s license, government or school ID, passport, etc.). Completed forms Your copay, if you have one. Ask for a receipt for your records. read privacy policy which tells you how they will keep your information private. It is required by the law. When you see your provider, it is helpful to share: Your family health history and medical records Medication you are taking (and the bottles so your provider knows what dose you take). If you need a refill, ask for one. Questions or concerns you have about your health – write them down so you don’t forget to ask. You may want to bring someone with you, friend or family member to help you talk to the provider. Don’t be shy! You should be able to answer these questions before you leave the provider’s office: How is my health? What can I do to stay healthy? What do I do next? Blood work or another test? If I have an illness or chronic condition what are my treatment choices? If I need to take medicine when do I take it and how much? Side effects? Generic?
- Before you leave the office make sure all your questions have been answered. Clarify with the nurse or provider any follow up instructions and how you will be contacted regarding lab results. Have refills been called in to the pharmacy of your choice. Have lab orders or x-ray orders been called in or do you need to take a written order with you. Your insurance company may have a specific lab your required to use. MAKE SURE YOU KNOW!!! Make sure you have prior authorizations or pre-certifications in place for specialist visits or for medical equipment. Between visits if you have questions or concerns call the providers office.
- Provider of service will send a claim to your insurance company after a service is rendered. The insurance company will review the claim for payment. You may be contacted by the insurance company if they need additional information to process the claim. The insurance company may need to know if you have other insurance i.e. work comp, Cobra or if the claim is accident related. Until you respond to the request for information the insurance will not process your claim. These requests can be driven by a diagnosis submitted by your provider. An EOB is an overview of the total charges for your visit and how much you and your health plan will have to pay. AN EOB is NOT A BILL and helps to make sure that only you and your family are using coverage. You may get a bill separately from the provider. (see example on page 34.) Terminology: Service Description, Provider Charges, Allowed Charges, Paid insurer, Payee, What you Owe, Remark code. Pay your bills promptly, some providers will not see you if you have unpaid medical bills. You may be able to go on line to look up your own health information, such as screening and test results or prescribed medications. An appeal is the action you can take if you disagree with a coverage or payment decision by your health plan. If you have a complaint or are dissatisfied with a denial of coverage for claims under your health plan, you may be able to appeal or file a grievance. For questions about your rights, or assistance, you can contact your insurance plan. If you think you were charged for tests or services your coverage is supposed to pay for, keep the bill and call the phone number on your insurance card or plan documentation right away. Insurance companies have call and support centers to help plan members.