Typical Medical Benefits Questions

The extent of your medical benefits depends on the type of health insurance policy you have. Health insurance policies provide a variety of benefits related to medical treatments for illness and injury as well as wellness visits to the family doctor. There also are different types of managed care plans that provide comprehensive medical coverage beyond preventative maintenance. Your insurance provider can give you detailed information regarding your plan's benefits.

Coverage

• A typical medical benefits question is what services are covered. The extent of your benefits is outlined in detail in your policy provisions. It is important to note that no insurance policy pays for all the services you and your family need. Basic and essential insurance plans provide limited medical benefits to cover basic needs, including routine doctor's visits, immunizations, laboratory work and X-rays. More comprehensive plans cover hospital stays, maternity care and mental health and substance abuse treatment.

Payments

• So, how much you will have to pay? Typically, you'll either have a deductible or co-pay. A deductible is a portion of your insurance services you have to pay before your insurance company pays covered expenses. A deductible can be a dollar amount or a percentage of the insurance claim. For example, if you have a $1,000 deductible and your medical expenses cost $4,500, you must pay $1,000 before your insurance company covers the remaining $3,500. Some policies include co-insurance, which requires policy-holders to pay a percentage of each claim above the deductible. Other plans have co-pays, where you pay a set amount based on whether it's a general practitioner, specialist, hospital or emergency facility. Co-pays typically are small, starting at $10.

Network

• A common question is, "What doctor can I see?" Many insurance companies have agreements with specific doctors, health care facilities and other providers. The agreement provides medical services to plan members at a reduced cost. With managed care medical insurance plans, you receive a list of "in-network" providers that offer reduced rates. If you use a doctor or hospital outside of your company's network, you will pay more for services.

Specialists

• Whether or not you can see a specialist is oft asked. Managed care plans, such as Health Maintenance Organizations or HMOs and Preferred Provider Organizations or PPOs, may require that you see a primary care physician within the network for a referral if you require more specialized care such as oncology or neurological treatment. Other insurance plans, such as those issued through private insurers or medical indemnity plans, allow you to see a specialist without a referral.