Important health benefits covered by most policies and information regarding provider networks
MANHATTAN, Kan. – People don’t tend to plan for illness or injury, but the unexpected does happen. Health insurance, like any other type of insurance, covers you for the unexpected. But it also can help improve your health if you use the many free preventive care benefits offered by your health insurance policy, said Roberta Riportella, Kansas Health Foundation professor of community health at Kansas State University.
The preventive services must be covered at no direct cost to you beyond your health insurance premium—the fixed monthly cost you pay for your health insurance policy. Preventive services include annual well-person exams, cancer screenings and many immunizations, as examples.
Preventive services makes up one of the “10 essential health benefits” covered by health insurance policies since the Affordable Care Act (ACA) was implemented, Riportella said. These health benefits are covered by policies in the Health Insurance Marketplace, in addition to most other policies obtained through an employer, a private insurer, TRICARE, Indian Health Service, Veteran’s Affairs, Medicare or KanCare, Kansas’ Medicaid program.
“Although referred to as benefits, they are actually items and services within 10 categories,” she said. “They include preventive services, outpatient care, trips to the emergency room, hospitalization, care before and after your baby is born, mental health and substance use disorder services, prescription drugs, services and devices to help you recover if you are injured or have a disability or chronic condition, lab tests, and pediatric services for children ages 0 to 19, including dental and vision care.”
Families might have other specific needs, and some policies provide additional coverage, Riportella said. Policies might also exclude specific procedures and services, such as vision and dental care for adults, which should be clearly spelled out in the policy. It’s important to pay attention to the benefit packages offered in the policies you are considering.
When selecting a health insurance plan that fits your needs and budget, make sure to look at the provider networks, Riportella said. To manage costs, insurers negotiate prices and contract with different doctors, hospitals, pharmacies, labs and other health care providers for services. These contracted providers will be considered “in the network” for your policy.
“This arrangement seems to work well for all involved,” Riportella said. “It works well to make sure that costs are managed for both the insurance company and you as an insured person. It also works well for the providers, because it channels patients their way.”
Some policies require that you see only network providers, she said, or the policies might require you to pay more or all of your medical fees if you visit a non-network provider.
“To keep your costs as low as possible, it is always best to see network providers,” Riportella said. “Check the policies you’re considering to see if your current provider is in the network, as well as the pharmacies and labs you normally use.”
In most cases, she said, providers will be in the network for the full plan year, but at times providers leave their contracts with insurance companies. This is why each time you make an appointment, ask the office staff to make sure that provider is still in the network.
If you want to see a specialist, some plans instruct you to visit a primary care provider before the specialist, Riportella said.
“In those plans, the primary care provider gives you a formal referral to a specialist if you need specialty care,” she said. “If you want the freedom to go directly to a specialist on your own, you will want a policy that does not require you to go through the primary care provider first. Pay attention to these differences in plans if this is important to you.”
If you are a frequent traveler, some plans allow you to use non-network providers in a medical emergency, but what qualifies as an emergency in the legal terms of the health insurance contract might not be what you consider an emergency, she said. Travelers might consider policies with national networks or expect to pay more if caught out of town when illness or injury strikes.
The Centers for Medicare and Medicaid Services offer a “From Coverage to Care” consumer roadmap for obtaining and using health insurance.More information about the ACA in Kansas is available through K-State Research and Extension fact sheets. The Kansas Health Institute also has numerous resources on its website.
If obtaining insurance through the marketplace, log on to Healthcare.gov. To learn more about how to enroll in the marketplace or KanCare, call the marketplace, available 24/7, at 800-318-2596.