Understanding Your Health Insurance

Insurance policies are intended to provide you and your family with protection from catastrophic expenses and losses. Whether your healthcare is covered through an individual or employer sponsored insurance plan, the Marketplace or a public health plan such as Medicaid or chip, it is very important to understand your policy. Healthcare insurance can be confusing and frustrating, but knowing the basics, including common terminology and how to find member assistance, will help you to get the most out of your policy and coverage.

Private Health Insurance Coverage

There are many types of health insurance coverage. Common types of plans include: HMOs (Health Maintenance Organizations), PPOs (Preferred Provider Organizations), ACOs (Accountable Care Organizations), HDHPs (High Deductible Health Plans) and Limit Benefit Medical Plans. Sometimes, a plan may be combined with an HSA (Health Savings Account) or an HRA (Health Reimbursement Account).
For your medical coverage to work well, it is essential to understand your policy and to insist on getting everything in writing. The policy explains what benefits are covered and are not covered, the insurance company's obligations, your obligations, and how to appeal if a claim is denied.
Of course, few of us are experts on medical coverage, but with an understanding of the basics, you will be able to ask the right questions. Begin by identifying the types of medical coverage. The details of any of these plans can vary. It is wise to understand your benefits before seeing a provider. Your coverage will depend on what type of plan you have. Some terms to understand include:

Health Maintenancy Organization (HMO)

Under this type of plan, you must use hospitals affiliated with and doctors employed by the HMO. Also you must get a referral from your primary doctor to see a specialist. Your total cost for each doctor's visit is usually limited to a co-payment and your doctor usually submits paperwork to the HMO for you. HMOs typically offer coverage for preventive care services.

Preferred Provider Organization (PPO)

This type of plan has a network of providers from which you may choose and there is usually a co-payment for each visit. You may have the option to see out-of-network providers, but you will have to pay more than if you see a network provider. You may not need a referral from your primary care physician to see a specialist if the specialist is also in the network. PPOs typically provide coverage for preventive care.

Point-of-Service Plan

This type of plan is the most flexible of all. It has provisions similar to the HMOs, PPOs, and Fee-for-Service plans. Much like an HMO, the lowest out-of-pocket costs come if you use specific participating providers. The next lowest out-of-pocket costs come from using listed providers, similar to a PPO. The highest out-of-pocket costs come from using providers that are not affiliated with the plan at all. The name says it all - the point (or place) where you receive the service influences your out-of-pocket cost.

Fee for Service Plan

Under a traditional fee for service (or indemnity) plan, you can go to any doctor you choose and you don't have to get a referral to see specialists. However, these plans are often more expensive than other plans. Fee-for-Service plans usually pay only for medical expenses related to illness and accident and not for preventive care. You will also have to pay for your expenses up to a pre-determined amount (or 'deductible') before the plan will pay any claims. Even after the deductible has been met, you may have to pay a portion of the expenses, often 20%, with the insurance company paying the remaining 80%. Unlike other types of plans, you may be required to pay for services up front and then submit the bill to the insurer for reimbursement.

Exclusive Provider Organization (EPO)

This plan generally operates like an HMO, but the providers are not employees of the EPO. An insurance company generally manages an EPO while an HMO is a business unto itself.

Things to Think About No Matter Which Type of Insurance You Have

  • Does the plan allow seeking out and using specialists that you need?
  • Which hospitals can you use?
  • Does the policy cover the type of medicines you need?
  • Does the plan cover the specific procedures and therapies you need?
  • Does the plan limit the number of times per year that a certain item or procedure will be covered?
  • Does the plan cover assistive technology?
  • Does the policy cover assessment for mental and physical disorders?
  • Is there a lifetime maximum limit on what the policy will cover?
  • Making Your Policy Work For Your Special Needs
Ask to work with one insurance case manager. This helps both the consumer and the insurance company by having one person that knows your needs and can manage your claims effectively. It is best for the individual or family to communicate with this person on an ongoing basis.
If you are denied coverage for a therapy, treatment, or an assistive device that is medically necessary, don't take "no" for an answer. Ask for the exact reason for the denial, then collect all documentation that explains the need for treatment and consult your insurance policy for the proper appeals process. Insist that your insurance company and all health care providers supply all information related to the claim in writing.
Keep detailed, written records of everything related to your child's condition. These will also be very helpful for tax deductions and in all necessary stages of appeals. Don't hesitate to appeal decisions that are not in your favor.
Ask your employer to change the benefits in your company's plan if the current benefits exclude what you need covered.

Covered Services

Check your policy to make sure you understand what services are covered. Sometimes services that are connected to a certain diagnosis will be covered, and sometimes not. (For example, Autism Diagnosis and Treatment is not always a service covered.)

In Network Provider

Some plans work with selected healthcare providers called a provider network. These providers are "in network" and have a contract with your insurance company to accept a contracted rate for full payment of services. If you choose to get care from a provider who is not included in your plan’s network, you will likely pay a greater percentage or the full cost of the care.
To find in-network providers, look at your current provider directory or go to your health insurance website and search.

Out of Network Provider

Out of network providers have not agreed to any set rate with your insurance company. However, if you need to use an out of network provider, you should contact your insurance plan to see if they will pay a percentage of the cost. Emergencies are usually covered as long as you contact them as soon as possible to explain the care.

Out-of-Pocket Costs

Out-of-pocket costs are those you must pay before your plan starts to pay. If you have met your out-of- pocket maximum, your plan will pay the rest of your cost in full. Depending on the type of plan, you may be required to pay:
  • A deductible, which is a set dollar amount you will pay before your insurance begins to pay its percentage. You pay full price to the providers until you have reached that set dollar amount. After that, you will pay only co-insurance and co-payments.
  • Co-insurance, which is your percentage after you have reached your deductible. For example, if you have 20% co-insurance, you will only pay 20% of in-network costs, and your insurance will pay the remaining 80%.
  • A co-payment, which is a fixed dollar amount you pay for covered service at each visit or purchase of prescriptions. Sometimes your co-payments will count towards your out of pocket maximum, depending on your plan. Also, there may be a lower co-payment for generic medications.
  • Out-of-Pocket Maximum, which is the most you will pay out-of-pocket in a benefit year for medical services. This amount includes your deductible, co-insurance, and sometimes co-payments. Once you have paid this amount, your insurance covers 100% of your in-network costs for the remainder of the benefit year.


Sometimes medications are covered under your health care plan. If so, it is important to know which medications are covered and if there is a preferred list of medications covered by your policy. If so, when a provider prescribes a medication, ask them to make sure your insurance will cover it before writing the prescription. You can also ask if a generic version of the medication is available, which may lower the co-payment.

Health Savings Account (HSA)

An HSA is an account that allows you to save money on a tax-free basis to pay for current health expenses before your insurance deductible kicks in. It allows you to contribute to this account from your paycheck before taxes to save for future qualified medical expenses. In order to have an HSA, you must be covered by a High Deductible Health Plan (HDHP). The advantages of having an HSA are you that earn interest on your savings. Similar to a retirement plan, unspent savings roll over to the next year, and both employees and employers can contribute to this account, which can stay with you if you change employers.

Health Reimbursement Arrangement (HRA)

An HRA is similar to an HSA in that they both allow you to pay for current health expenses and save for future qualified expenses on a tax-free basis. An HRA earns interest over time, and employers have the option to allow you to roll over unspent funds to the next year. However, unlike the HSA, only the employer can contribute to this account, not the employee, and it does not stay with you if you change employers.
You should use your HSA or HRA to pay for all qualified services until you have reached the amount of the deductible or out of pocket maximum. Most HSA/HRA accounts have a checkbook or debit card that you use to pay for health expenses.
If you have health insurance through your employer, refer to your benefits plan summary or contact your employer's Human Resources department for details. If you purchase your own insurance, contact your insurance company for a summary of benefits.

Medicaid and CHIP (Children’s Health Insurance Plan)

Medicaid is an insurance program for people with low income that provides health coverage for children, pregnant women, many seniors, and/or people who are blind or have other disabilities. The program is jointly funded by the State and Federal government.
Each state runs its own Medicaid program and determines the covered benefits through a state plan, and a federal agency known as the Centers for Medicare and Medicaid Services (CMS) monitors the programs in each state and sets standards for how the programs are managed and financed.
CHIP is a state health insurance plan for children who are not eligible for Medicaid because of income eligibility but do not have any other health insurance. Depending on income and family size, children who are under the age of 19 may qualify. Like Medicaid, CHIP is different in each state.


Medicaid and CHIP eligibility is determined at the state level and is income-based, so each individual and family can find their state’s policy on the Medicaid website.


Because Medicaid and CHIP are both administered by states, benefits vary. However, there are minimum federal care standards to be provided to all Medicaid enrollees. All Medicaid enrollees receive the following mandatory benefits:
  • Inpatient hospital services
  • Outpatient hospital services
  • *EPSDT: Early and Periodic Screening, Diagnostic, and Treatment Services
  • Nursing Facility Services
  • Home health services
  • Physician services
  • Rural health clinic services
  • Federally qualified health center services
  • Laboratory and X-ray services
  • Family planning services
  • Nurse Midwife services
  • Certified Pediatric and Family Nurse Practitioner services
  • Freestanding Birth Center services (when licensed or otherwise recognized by the state)
  • Transportation to medical care
  • Tobacco cessation counseling for pregnant women
*All children enrolled in Medicaid receive comprehensive care services titled: Early, Periodic Screening, Diagnosis and Treatment (EPSDT). Those services include immunizations, sick doctor visits, regular checkups, vision and dental care, and others services deemed medically necessary by the primary care physician. If a service is deemed medically necessary it can be covered for children under age 19 even if it is not a covered benefit in the state plan.

How to Enroll

Each state has its own means of enrolling individuals and families in Medicaid and CHIP. To enroll your child in Medicaid or CHIP in your state site, go to Insure Kids Now.

Finding a Medicaid Provider

Once an individual or family is enrolled in Medicaid, it’s important to know that every provider does not accept Medicaid coverage. Finding a doctor or hospital that accepts Medicaid can sometimes be challenging, depending on your location. Most state Medicaid websites have searchable provider lists for enrollees. Another way to locate health care providers who accept Medicaid is to call the Member Services number on your Medicaid card and speak with a representative who has up-to-date lists of providers in your area.


Information & Support

For Parents and Patients

Health Insurance Marketplace
Also known as the health insurance exchange, the Health Insurance Marketplace helps uninsured people find health coverage that meets their needs and budget. Part of the Affordable Care Act.

Take Care Utah
Health insurance outreach and enrollment assistance to Utah residents. Also provides training and resources to community-based organizations that assist Utah's diverse populations and needs. All services are provided free of charge; a partnership between the Association for Utah Community Health (AUCH), the Utah Health Policy Project (UHPP), and the United Way 2-1-1.

List of states and number of programs for each state.

Insure Kids Now
Your child or teen may qualify for no-cost or low-cost health insurance coverage through Medicaid and the Children’s Health Insurance Program (CHIP). Many parents may also be eligible.

Social Security Administration
Disability determinations are generally made by a disability determination service (DDS) and can take several months. However, if a child has a diagnosis that provides for presumptive eligibility, a letter from the doctor certifying the diagnosis and its severity will allow for the patient to begin to receive services for up to 6 months while the application is being processed.

Utah Insurance Department
Fosters a healthy insurance market by promoting fair, reasonable and responsive practices that ensure available, affordable and reliable insurance products and services.

Tracking Medical Bills (Word Document 125 KB)
This form, developed for Tennessee's Family Information Notebook, provides a way to track bills including dates, insurance company, who paid, and more. For a PDF version and other forms, see the Care Notebook page.


Health Insurance Advocacy

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Public Health Services

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For other services related to this condition, browse our Services categories or search our database.


Authors: Tina Persels - 1/2016
Gina Pola-Money - 1/2016