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Insurance FAQs
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We encourage you to check directly with your insurance plan to get specific answers to questions about your coverage and benefits. Many plans have web sites and customer service numbers. You can also consult your benefit plan book or contact your Human Resources department.
Common insurance terms and meanings
- HMO, PPO, EPO?
- What is a Deductible?
- What is a Co-payment and co-insurance?
- How does the hospital know when I owe a deductible or co-insurance, and how much that amount is?
- What is an "EOB"?
Spouse and dependent questions
- How does billing work when I am covered by both my insurance and my spouse's?
- My children are listed as covered dependents on both my insurance policy and my spouse's polity. Which policy should pay as the primary policy?
Network provider questions
- What difference does it make if I go to an "in-network" provider or an "out-of-network" provider?
- Who decides whether a provider is "in-network" or "out-of-network"?
- Why do I get a bill from both the hospital and any doctors who saw me while I was at the hospital?
- If the hospital is part of my insurance plan's "in-network" providers, why aren't all the doctors who practice at the hospital also "in-network" providers?
Common insurance terms and meanings
HMO, PPO, EPO?
PPO stands for Preferred Provider Organization. As a general rule, purchasing this type of coverage will allow you to go to a range of providers who have contracted with the insurance plan to provide services either at a rate that is lower than the provider's full-billed charges, or for some other type of volume considerations. HMO stands for Health Maintenance Organization. These types of coverages usually have a more restricted list of providers, which you can go to, and may have stricter rules on what is required to obtain care from specialists. HMO's also may have lower deductibles and other out of pocket costs. EPO refers to Exclusive Provider Organization and can act in the same manner as either a PPO or an HMO, depending on how your insurance plan defines them.
What is a deductible?
Generally, a deductible is a flat, annual amount, which must be paid by the plan member before the insurance plan payment benefit will be available. For example, if your deductible is $500, then you must pay that amount out of pocket before the insurance plan will pay any medical expenses.
What is a co-payment and co-insurance?
A co-payment is an amount the patient must pay each time they have a service (doctor's office visit, emergency room, etc.), which is subject to a co-payment. Co-payment information is often listed on the back of your insurance card. Co-insurance is an amount also applied to medical services, typically a percent of the full service. Most co-insurance obligations have an annual maximum amount and once you have paid it you will not owe anything for the remainder of the plan year.
How does the hospital know when I owe a deductible or co-insurance, and how much that amount is?
Providers go by the information supplied to them by your insurance plan and bill you accordingly. If you disagree with a deductible or coinsurance bill, contact your insurance plan to see how the amount was calculated.
What is an EOB?
EOB stands for Explanation of Benefit. Most insurance plans will send you an EOB each time they process a payment to a health care provider. The EOB should tell you exactly how much the insurance plan paid to the health care provider and how much you will owe.
Spouse and dependent questions
How does billing work when I am covered by both my insurance and my spouse's?
If you are the patient, your insurance will be the primary insurance and will pay your bill first. Any amount you owe after your insurance pays will be sent to your spouse's insurance plan, which is considered your "secondary" insurance. If your spouse is the patient, then his/her insurance policy will be the primary insurance and yours will be considered the secondary insurance for them.
My children are listed as covered dependents on both my insurance policy and my spouse's polity. Which policy should pay as the primary policy?
When the patient is listed as a dependent, spouse or domestic partner on another insurance policy, then what's called the "Birthday Rule" applies. Whichever parent has a birthday earlier in the year will be considered the primary insurance. For example, if the children's mother's birth date is March 15th, and the children's father's birth date is July 10th, then the mother's insurance will be the primary insurance and the father's insurance will be the secondary insurance.
Network provider questions
What difference does it make if I go to an "in-network" provider or an "out-of-network" provider?
This is a question you must ask your insurance plan, since they set the benefit payment rules for "in-network" and "out-of-network" providers. There could be a number of restrictions your plan might impose for receiving services from "out-of-network versus an "in-network". Some of these may include financial penalties or coverage limitations.
Who decides whether a provider is "in-network" or "out-of-network"?
Which providers (such as a doctor or hospital) are "in" or "out" of an insurance plan's network is decided solely by each insurance plan. Often the designation depends on whether or not the insurance plan has a contract arrangement with the provider, although that may not always be the case. You must check with your insurance plan about a particular provider's status.
Why do I get a bill from both the hospital and any doctors who saw me while I was at the hospital?
The physicians who practice at our hospitals are independent contractors&,dash;they are not employees of the hospital. As independent contractors, they bill for their services, and the hospital also sends a bill for its services. If you see multiple physicians during your stay in the hospital, then you will receive a bill from each of the physicians who rendered care to you during your stay. This will include physicians you may not realize rendered care to you, such as the radiologist who read and interpreted your x-ray.
If the hospital is part of my insurance plan's "in-network" providers, why aren't all the doctors who practice at the hospital also "in-network" providers?
As independent contractors, the physicians are free to contract with any particular health plan. Because the physicians are independent providers, the hospital does not require that the physicians be part of the "in-network."