1. Familiarize yourself with your insurance coverage by accessing the website on the back of your insurance card. There will also be 1-800 number that you can call to speak with a customer service representative for your insurance company. Specifically, determine:
Is there a deductible to meet? A deductible is an amount that you will need to pay before your insurance company starts paying their portion of the cost. If so, you will want to know: How much is the deductible, and How much has been met to date?
What is my co-pay or co-insurance? A co-pay is the financial amount that you will be responsible for paying at each appointment. Your insurance company may provide you with an actual dollar amount (e.g., your co-pay is $35 per appointment); OR they may tell you the percentage that they will pay for each visit, in which case your co-insurance is the remaining portion you are responsible for (e.g., you insurance pays 80% and your co-insurance is 20%).
2. Access the website listed on the back of your insurance card and be prepared to input your Insurance ID Number (located on the front of your card), your birthdate, and your home address.
3. There will be a “Find a Provider” or “Doc Find” link embedded. Narrow the search criteria to the area of interest (Primary care, specialty care, dermatology, etc.), and the geographical area; usually a zip code or a specific mile radius from Salem. This will provide a list of “Preferred Providers”
4. Start calling the “Preferred Providers” listed to see if they are taking new patients. If so, ask for an initial appointment to establish care. Be prepared to make a few calls and expect a wait time for an initial appointment.
Insurance coverage and costs vary considerably by plan. It will be important to familiarize yourself with several key terms:
Co-pay: One of the ways you share in your medical costs. You pay a flat fee for certain medical expenses (e.g., $25 for every visit to the doctor), while your insurance company pays the rest.
Deductible: The amount of money you must pay each year to cover eligible medical expenses before your insurance policy starts paying.
Co-insurance: The amount you pay to share the cost of covered services after your deductible has been paid. The coinsurance rate is usually a percentage. For example, if the insurance company pays 80% of the claim, you pay 20%.
Health maintenance organization (HMO): A health care financing and delivery system that provides comprehensive health care services for enrollees in a particular geographic area. HMOs require the use of specific, in-network plan providers.
In-network (sometimes called “Preferred”) Provider: A health care professional, hospital, or pharmacy that is part of a health plan’s network of preferred providers. You will generally pay less for services received from in-network providers because they have negotiated a discount for their services in exchange for the insurance company sending more patients their way.
Out of Network (sometimes called “Non-Preferred”) Provider: A health care professional, hospital, or pharmacy that is not part of a health plan's network of preferred providers. You will generally pay more for services received from out-of-network providers.
Out-of-pocket maximum—the most money you will pay during a year for coverage. It includes deductibles, copayments, and coinsurance, but is in addition to your regular premiums. Beyond this amount, the insurance company will pay all expenses for the remainder of the year.
Preferred provider organization (PPO): A health insurance plan that offers greater freedom of choice than HMO (health maintenance organization) plans. Members of PPOs are free to receive care from both in-network or out-of-network (non-preferred) providers, but will receive the highest level of benefits when they use providers inside the network.
Premium: The amount you pay each month or year in exchange for insurance coverage.