December 15, 2007
Although YKHC receives government funding through the Indian Health Service, our financial viability depends on also being able to bill Medicare, Medicaid and health insurance companies for services we provide to patients who are eligible for such coverage or do not qualify as IHS beneficiaries. The more you understand about why we do this and how insurance companies operate, the better we can help you - while also keeping us financially healthy.
This is the first of a series of articles about health insurance, starting with the basics.
Health Insurance Basics
by Joan Carr, YKHC Revenue Supervisor
Understanding health insurance can be frustrating as well as frightening. This article will help you understand the basics.
Health insurance information is most needed when someone is sick. This is not usually a time when anyone wants to take the time to understand it.
Here are some basic definitions, with understandable explanations:
Participating Provider - a physician or other healthcare provider that is part of your insurance plan's network of providers. This provider can be an ambulance company, a hospital, a pharmacy, optometrist, medical equipment supplier, physical therapist, etc.
Tip: Whenever you change insurance companies make sure your providers will be a part of the new plan's network; otherwise, services may not be covered or may require higher payments from you.
Deductible - a yearly out-of-pocket cost to you as part of your insurance plan. This amount must be paid by you before your insurance will pay. For example, if your deductible is $75 and the visit to your physician's office was $100, you would have to pay the deductible and your insurance would pick up the $25, if the $100 was the allowable fee.
Allowable Fee - sometimes called the contracted amount, this is what your plan will pay for a specific service, if the service is covered in your plan. For example, a covered service under most plans is an office visit for a sinus infection. An office visit for ear piercing is usually considered a non-covered service and most insurance plans will not pay for this. In the previous example, as long as the visit is covered, your insurance should pay the $25.
Co-Pay - the amount you pay every time you get a medical service. Some insurance plans have different amounts for specialists and the emergency room. These amounts are usually printed on the front of your insurance card. It is important to bring your insurance card with you when you go to get medical care. The physician's office or hospital will need the information on the front (group number and member number) as well as the correct billing information (usually found on the back of your card).
Primary Insurance - This is the first insurance that will pay on your claim. If you have more than one insurance, it is important for you to know the order in which the insurance plans will pay.
Secondary Insurance - This is the second insurance that pays. Most people think the husband's insurance pays first and the wife's insurance pays second; this is not necessarily true. Contact your insurance plans for the specifics. Some secondary plans will pay for the deductible from the primary insurance. In our previous example, the secondary insurance could have paid the $75 deductible. Do not assume this will happen, it is best to check.
Always remember that the best time to get this information from your insurance plans is before you are ill or have an emergency. Your employer and your plan's benefit book or customer service department are your best resources.
If you have specific questions about a YKHC bill, our patient information line is available. Please make sure you have your insurance information with you when you call to discuss your bill: Patient Accounts 907-543-6398
