Understanding Your New Health Insurance

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 Health insurance can be confusing.  Here are a few tips to help you understand your new health insurance.  

How do I find a network provider?

 

Your health plan will have a list of in-network providers.  This information is also often available online as part of your insurer’s website.  If you need to see a specialist, you may need to obtain a referral from your primary care provider before you receive services even if the specialist is in your network.  Contact your health plan before you make an appointment to verify the plan’s requirements. 

  

How will I know how much a procedure will cost? 

 

To avoid billing surprises, always price a procedure in advance.  For in-network procedures, contact your plan for your out-of-pocket responsibility.  For out-of-network procedures, first contact the provider for the procedure price and then contact your plan to verify your financial responsibility.  

 

Typically plans will only pay a percentage of the allowed amount for an out-of-network procedure.  This amount is typically lower than the amount the provider charges.  When you receive out-of-network care, you must pay your percentage plus any remaining balance charged by the provider. 

 

How do I challenge a denial of benefits? 

 

Your health plan will review any claim for treatment or service.  If your plan refuses to pay for medically necessary services, treatments, or medications, you have the right to appeal the decision through the plan’s internal appeals process.  Contact your plan for details on the appeal process. 

 

If you have exhausted your internal appeal rights, you may have the right to have the decision reviewed by an independent review organization (IRO).  Your health plan must provide an IRO form if it denies payment based on a decision that the treatment is unnecessary, inappropriate, experimental, or investigational.  

 

For more information on IROs, contact the Department of Insurance’s Network Certification and Quality Assurance Office at (866) 554-4926 or visit its website at https://www.tdi.state.tx.us/wc/wcnet/

 

What happens if I overpay my provider? 

 

Your provider must refund any overpayments.  Contact your provider’s office if you think you have overpaid.  

 

 

 

 

I joined OPIC as a staff attorney in 2011.  I specialize in life, health, and disability insurance law.  I know that consumers can find themselves frustrated with these insurance issues at very difficult times in their lives—during sickness, after an injury, and after the loss of a loved one.  I am grateful that I can utilize my expertise to educate and empower insurance consumers as they navigate these challenges.