Insurance 101

With the health care insurance environment becoming more complicated and complex here are some tips to help you better understand and manage your current plan.


                BRING YOUR CURRENT INSURANCE CARDS AND DRIVERS LICENSE TO CONFIRM PROOF OF COVERAGE. Plans may change from year to year-your employer may have renegotiated a new plan or changed plans altogether or you may have a new plan purchased on the Healthcare exchange.



  1. Commercial plans are provided by employers and premiums are paid via your employer and payroll deductions. Your coverage is based on the contract between your employer and the insurance company. Most employers provide benefit booklets each year for you know and understand your coverage before going to the doctor.
  2. Healthcare Exchange plans are plans purchased through and paid independently by the policy holder. In Alabama, BCBS of Alabama is the only company to offer these plans. These plans have many levels of coverage with plan specific guidelines that you must follow in order for claims to be paid. Coverage details may be obtained through the BCBSAL patient portal. Patients who are in their “grace period” between premium payments will be asked to reschedule all appointments until premiums are paid.



  1. Is your plan a PPO, HMO or POS plan? It is generally listed on your card and you should know prior to making any appointments with your doctor.
    1. PPO is a Preferred Provider Organization that allows you to visit any doctor without a referral that is considered in network. Your plan will provide you with a list in in network providers. Your coverage is based on your contract. Make sure you understand your terms of care and which doctors accept your plan.
    2. An HMO is a Health Maintenance Organization that requires you to choose a Primary Care Physician(PCP) to help coordinate your care. HMO’s often contract with specific providers so check to make sure your doctor is a participant in your plan. If they are not you may be responsible for all costs associated with that visit.
    3. A POS is a Point of Service plan that is similar to an HMO in that you need a designated PCP to help your coordinate care. You may be able to choose your own specialist but may pay higher fees if you use someone considered out of network.

We always stress that you should know and understand the terms of your health care contract before going to the doctor. Your doctor only has access to minimal information about your plan. It’s best to know prior to receiving care so you don’t get bills that you don’t expect.


  1. What is your deductible and how does it apply to your care?
    1. Comprehensive deductibles are very common in today’s insurance environment. A comprehensive deductible is the designated amount of money that you pay out of pocket FIRST prior to your insurance covering your care. You may be asked to pay part or all of your visit if you have a comprehensive deductible.
    2. Major medical deductibles are often applied to care that is defined as major medical by your plan. This often includes surgery and hospital related charges as well as outpatient testing such has MRIs, CT scans or diagnostic mammograms. Some in office procedures such as colposcopies, ultrasounds or more complex procedures may be subject to a major medical deductible.

Ask your doctor to provide you with codes prior to scheduling any procedure so you can call your insurance to see how they pay for that care. Ask specific questions such as “how does my deductible apply to that procedure?” Always ask for the agent’s name and get a reference number when you call.


  1. Does your plan require you to use a plan specific laboratory for blood work and pathology? You MUST be certain of your lab coverage before going to a doctor’s visit that may require blood work or pathology. Many BCBS of Alabama plans use Quest Laboratory as their contracted lab.

This information is vital as you may receive large out of network lab bills if you fail to use the correct lab.


  1. Are you a Medicare eligible? If so, you have choices in coverage but keep in mind that all Medicare plans follow traditional Medicare rules and policies. Make sure your doctor of choice accepts your plan before choosing a plan.  All Medicare plans cover medically necessary care and have guidelines for preventative care that you should be aware of prior to scheduling appointments for care.
    1. Medicare Part B or traditional Medicare. Part B is physician coverage only and covers your care at 80%. You will be billed for the remaining 20% once Medicare has paid. Many Part B holders choose a secondary plan to help pay for the portion that Part B does not pay. Secondary plans follow Medicare policies and will not pay if Medicare does not. Many Part B patients will choose Medicare Part A for hospital coverage and Part D for prescription coverage.  There are other prescription plans available to Medicare eligible patients. You can sign up for Medicare Parts A and B at your local Social Security office or online at
    2. Many commercial plans such as BCBS, UHC, Humana, Cigna and Aetna offer Medicare plans. These plans include:
      1. Health Maintenance Organizations(HMO). These plans require that you use doctors contracted with the plan to provide service. You may have to choose a PCP to help manage your care and provide referrals to other doctors. Prescription coverage often is included in Medicare HMO plans. Know which doctors participate prior to making an appointment.
      2. Preferred Provider Organizations(PPO). These plans offer you more freedom to choose your own doctor as long as they are defined as in network.  Many of these plans offer prescription coverage
    3. Prescription plans are often separate if you do not choose Part D. Many commercial plans provide prescription only coverage. You can visit to find the right prescription plan for you.

If you choose a Medicare plan that is not traditional Medicare Part B you may also be subject to rules and policies specific to that commercial plan (i.e UHC plans require precertification on all surgeries). It is very important to know what your terms of coverage for all Medicare related plans.


  1. Many commercial, exchange and Medicare plans have formulary lists assigned to their plans. This means your prescriptions coverage may be tiered and certain branded and generic medicines have to be approved by your plan before prescribing. This is an arduous process that could take up to 3-5 business days to complete. We work very hard to get your medicines prescribed as quickly as possible but must wait for your plan to approve before prescribing.


  1. We call for precertification on all outpatient surgery procedures. Your plan may require that you follow certain steps in care before they will authorize surgery. Precertification can take up to 15 days with some insurances as they review the need for surgery. We normally do not schedule until precertification is obtained.  Letters of Predetermination are often required for certain procedures. It is best to check with your plan for coverage details before you schedule any surgery or major procedure.