What is a network?
A network is a group of healthcare providers (doctors, hospitals, etc.) who have come together and agreed to charge negotiated (usually lower) rates for the services they provide. If you stay within your health plan’s network of participating healthcare providers, your out-of-pocket expenses are typically lower; if you stray outside the network, however, you may feel it in your wallet.
The three most common types of provider networks you will come across are:
- PPO (Preferred Provider Organization): The health insurance plan offered to the students of Pace University utilizes a PPO network. In a PPO you choose from doctors within your network, but you don’t have to designate one doctor as your Primary Care Physician (PCP). PPOs offer out-of-network coverage, though you pay a higher portion of the cost if you use non-network providers. There are many PPO networks throughout the country, some of which have providers located everywhere in the US, and others that only have local providers. The name of the PPO utilized by the Pace University health insurance plan is UnitedHealthcare Options PPO. To find a list of providers within this network, click on the following link: https://www.providerlookuponline.com/UHC/po7/Search.aspx
- HMO (Health Maintenance Organization): Generally, in an HMO you select a primary care physician (PCP) who coordinates your care and refers you to specialists when needed. If you get care from a provider without a referral from your PCP, or someone not in the network, expect to pay more of the cost and potentially the full cost yourself unless you need care that no physician in the network can provide.
- POS (Point of Service): Almost a combination of an HMO and a PPO, with a POS you can choose to get care from both network and out-of-network physicians. In many POS plans, if you get a referral from your PCP, you don’t pay as much as you do if you bypass your PCP.
Understanding What You Pay For
- Annual maximum: An upper limit on costs or services covered by a plan. For example, a plan may put a ceiling on the dollar amount of coverage it will provide over the course of a year (this limit will be removed from all plans in 2014).
- Copayment (Copay) or coinsurance: A dollar amount (copay) or percentage (coinsurance) you’re responsible for paying for your covered healthcare services. You may have to pay a set amount every time you make an office visit, a different amount for lab work, and various amounts for different types of prescription drugs. You may have to meet a deductible before your copay or coinsurance kicks in.
- Deductible: The amount you have to pay for covered medical services before your health plan starts chipping in. Your deductible amount may be very small or quite large. What size it is depends partly on you: you can trade off the costs of a high deductible with a lower premium, and if you’re young, healthy and don’t have dependents, this may be the way to go. Some employers have plans that don’t have a deductible and pay for covered benefits from the first dollar you spend. They’re called first-dollar plans.
- Exclusion: A health condition or circumstance not eligible for coverage under your health plan. What your plan doesn’t cover is listed in the Certificate of Coverage for your benefits.
- Premium: The cost of an insurance plan. Your employer may pay all or part of your premium if you get your health benefits through your company.
- Reimbursement: A payment either to you or a healthcare professional for covered medical services. A fee-for-service plan may reimburse you or your doctor a set amount or maximum amount for specific services. For example, if you fill a prescription using the Pace University student health insurance plan, you will be asked to pay for the prescription up front. You will then be reimbursed a portion of that amount depending on whether you received a name-brand or generic version of the medication.
Reading Through Your Explanation of Benefits (EOB)
Every time you or your doctor files a claim with your insurance company, you will receive an Explanation of Benefits (EOB) or claims statement. This form is usually mailed to you, but may be available on your insurance company’s website, guarded by your own personal password, or on your own personal web page.
The EOB explains how your health benefits claim was processed. It is important to note that an EOB IS NOT A BILL. As well as your name and policy information, the form usually includes:
- Date of Service
- Who provided the service
- The service provided
- The Claim amountThe agreed-upon amount paid by your plan
- The amount you’re responsible for paying
If you are enrolled in the student health insurance plan through Pace University and have filed a claim you can check on the status of that claim by going to: https://www.uhcsr.com/SelfServiceSupport/Students/myAccount/AccountLogin.aspx
For a good source with additional information about healthcare benefits, go to www.planforyourhealth.com. This site includes information on healthcare reform, as well as tips and tools to help you pick which health plan best fits your needs.