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Responsibilities of a Health Insurance Subscriber

In health insurance terms, a subscriber is the person who signs up for the health plan. Some health plans may call subscribers "enrollees" or "members." Health plans often create a list of subscribers' "rights and responsibilities" that's distributed to all subscribers and posted on the plan companies' websites. These responsibilities vary from treating providers with respect to following a prescribed treatment plan. However, certain responsibilities of the subscriber affect the core functions of the health insurance process, including preauthorization, payments and coordination of benefits.

  1. Obtaining Preauthorization

    • Health plans usually require preauthorization for services such as surgery, hospitalization and specialist doctor visits, among others. Though the doctor or hospital providing the services is often the one who contacts the health insurance plan for its approval, ultimately it's the subscriber's responsibility to make sure that preauthorization is obtained before services are rendered. If the subscriber doesn't get the correct preauthorization, services may not covered, which leads to denied claims and the subscriber stuck paying the bill.

    Copays, Coinsurance and Deductibles

    • Health insurance plans usually have out-of-pocket costs to the subscriber. The subscriber is responsible for paying required copays, coinsurance and meeting plan deductibles. The deductible is a dollar amount that the subscriber pays for health-care services before the health insurance plan pays. Copays --- payments made to a doctor or facility at the time of service --- and coinsurance, which is a percentage of the health-care expenses that the subscriber is required to pay, are two out-of-pocket expenses.

    Notification of Other Coverage

    • If the subscriber has coverage through more than one health plan, he's responsible for notifying both health plans. This may be input on the subscriber portal of the health insurance plan's website. Subscribers need to let their providers know all of the insurance coverage they may have. The health plans coordinate benefits between each other to decide who pays what portion of the subscriber's medical expenses. The National Association of Insurance Commissioners establishes rules that the plans often use to determine which subscriber plan is primary and which is secondary.

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