Understanding Health Insurance Coverage for OB-GYN Care

Quick look at understanding health insurance coverage

Understanding health insurance coverage helps patients be better informed about their potential treatment costs, while putting them at ease with their overall experience in our practice.

Knowing how to use health insurance at CU Medicine OB-GYN East Denver helps patients feel more confident in accessing the healthcare they need.

Being familiar with key terms, such as premium, deductible and copays, and the different types of insurance plans is essential to getting the most out of any health plan.

Learning about OB-GYN insurance details, such as referrals requirements and coverage for specific treatments, further empowers patients to take control of their healthcare.

The basics of using health insurance

• Know what type of insurance plan you have, what the coverage period is and who is covered (individual only, spouse, family members).
• Gather related information such as your insurance card, your member ID number, and how to contact your insurer to get particulars on your coverage and benefits.
• If your plan has in-network and out-of-network coverage, learn if CU Medicine OB-GYN East Denver and its providers are in network.
• Know about your plan’s premiums, deductibles, copay or coinsurance responsibilities, coverage limits and out-of-pocket maximums if applicable.
• Understand what medical services and specialists you may need a referral for, including how to arrange for a referral to our practice.
• Some insurance plans require prior authorizations to pre-approve medical services.
• See what kind of medication coverage is included in your insurance plan.
• Know how your insurance plan covers emergency care, including hospital emergency room visits and urgent care visits.
• Call your plan’s administrator to get help with any of these issues before contacting us for insurance-covered care.

Types of insurance health plans

Health insurance is a package of covered services and items with specific rules on how much the plan will pay for each. Most health plans generally last for a year and then must be renewed annually, though multi-year plans do exist.

The types of health insurance available are based on the provider of the plan, which could be employers, the private individual or the government. Health insurance in the United States is described as a mixed system in which private plans and government plans are available to provide healthcare coverage.

Employer health insurance

In the U.S. about half of the population receives health insurance through their employer. Employer-based plans can have a variety of coverage options, premiums, deductibles, and employee copay or coinsurance amounts. These plans often make insurance available for the employee’s spouse and children.

Private health insurance

Also called individual health insurance, this type of insurance is purchased by an individual on the open market, with the individual paying the premiums. These plans, which can also cover a spouse and children, are generally available by geographic region where the insured lives.

People can purchase these plans by themselves, through a broker or private insurance agent, or through a government’s health insurance exchange.

Connect for Health Colorado is our state’s exchange marketplace.

The Affordable Care Act (ACA) provides a federal Health Exchange Marketplace for private insurance plans.

Please note that Connect for Health Colorado and the ACA are not government insurance plans.

Health Savings Account

A Health Savings Account (HSA) is a savings account for those with private health insurance to be used for healthcare costs that are tax free. People with a high deductible health insurance plan are eligible to open an HSA, available through banks and other financial institutions.

Funds from an HSA can be used for qualified costs such as copays, deductibles and other services and items, such as medications, acupuncture, ambulance costs and more.

Government health plans

Government provided healthcare insurance can be federal or state.

Federal plans:

• Medicare, for people over age 65.
• Medicaid, for people and families with low incomes.
• Veterans Administration plans, for military veterans.
• TRICARE, for active service military personnel and their families.

Colorado state plans:

• Health First Colorado, the state’s Medicaid program.
• Child Health Plan Plus, for eligible children and pregnant people who are not eligible for state Medicaid.

These plans have different requirements for enrollment, as well as various benefits and coverage details.

Understanding common health insurance terms

While there are many variations in health insurance plans, the same terms related to coverage and payment usually apply to all in some fashion.

Insurance cost terms

Premium. This is what the insured pays to have a health plan. This can be a monthly, quarterly or annual payment. Employers often pay the premium or part of it for those with an employer provided health insurance plan.

Cost sharing terms. These relate to costs for healthcare services that are paid by both the insured person and the insurance provider. Types of cost sharing include deductibles, co-payments and coinsurance.

Deductible. The share a patient has to pay for a covered service before their health insurance plan pays. If a patient’s insurance plan has an annual $2,000 deductible, the insurance plan does not make any payments until the patient has paid $2,000 of their own money (known as an out-of-pocket cost) on medical services.

Copayment. This is a fixed charge for a particular health service the patient is required to pay, typically after they have met their annual deductible.

Coinsurance. Although similar to a copayment, coinsurance is based on a percentage of the service’s cost a patient has to pay after they’ve met their annual deductible. For example, instead of a fixed $30 copay for a service, the patient might have a coinsurance payment of 15% of the service’s cost.

Out-of-pocket maximum. This is an option in many plans that puts a cap on the patient’s out-of-pocket payments for healthcare services over the term of the insurance plan (usually a year). Once the patient has met that level of out-of-pocket payments, the insurance plan generally pays 100% of covered care moving forward.

Services for no fee. Some plans do not charge patients for particular services, such as preventive screenings and vaccinations (see additional information further below).

Explanation of benefits (EOB). An EOB is an important document for tracking insurance coverage, costs and payments. Insurance plans typically will send an explanation of benefits to a patient following care to show what is covered and what the patient is responsible for paying. The EOB also shows what the insurance plan will pay the medical provider for the service.

Patients should consult their plan before having a particular healthcare service performed to make sure they understand the EOB.

Open enrollment. Open enrollment is a set period, typically in the fall, when individuals can make changes to their insurance plans as well as switching to a different plan. Employers who provide insurance coverage set their own open enrollment period. ACA marketplace open enrollment typically runs from November 1 – January 16 in most states.

Understand prior authorization to make sure you’re covered

A prior authorization is used by insurance plans to pre-approve medical services to ensure the treatment is covered by the insurance plan and is medically necessary. Also called a pre-authorization, some insurance plans require prior authorizations for complex treatments or medications.

While prior authorizations are submitted by healthcare providers to a patient’s insurance plan before performing the service, patients can check their own plan coverage. In fact, it is a good idea to review your plan to know when you will need a prior authorization.

We recommend that patients reach out to their insurance providers to confirm their benefits annually. Reviewing your benefits is especially important when you have a new or updated insurance plan, and even renewed plans often have changes in coverage.

To find out if your insurance covers a procedure, you can review your insurance policy documents, visit your insurance company’s website or call their customer service line. To make sure that you receive accurate information, provide the diagnostic code for the procedure. Existing patients can request billing codes via their patient portal, My Health Connection, or by calling our office.

HMOs, PPOs & in-network vs out-of-network

Many insurance plans are either an HMO (health maintenance organization) or a PPO (preferred provider organization). Both have agreements with a network of medical providers, hospitals and other health service providers. HMOs typically cost the patient less than PPOs.

HMO

In an HMO the patient generally benefits from lower costs for services that the insurance plan has negotiated with the in-network providers. Using a provider outside of network most often is not covered at all, except for emergency visits.

HMO patients generally have a primary care provider who acts as a gatekeeper and makes referrals to in-network specialists for healthcare services like OB-GYN.

PPO

In a PPO the patient pays less for care from a provider in that PPO network. In many cases the patient can still get partial coverage for care by an out-of-network provider, although not always.

In-network & out-of-network

In most cases, the care performed by an in-network provider will be less expensive – often considerably so – for the patient than care from an out-of-network provider. Some HMO and PPO plans have in-network deductible amounts and out-of-network deductible amounts.

The differences between in-network service and out-of-network service are very important for patients to understand.

Specifics about OB-GYN care and insurance coverage

The Affordable Care Act mandated certain coverages with no cost, or little cost, to the patient for most insurance plans in the U.S. These medical services include wellness exams, mammograms, cervical cancer screening, prenatal care, contraception (though not all brands) including tubal ligation, and more.

Patients can learn more in the Women’s Preventive Services Guidelines from the Health Resources & Services Administration.

Individual health plans can have special coverage for additional obstetric and gynecology services. Please check individual plans for such benefits.

Our obstetrics providers most often deliver at Rose Medical Center. CU Medicine OB-GYN East Denver obstetrics patients should check with their insurance plan to see if it covers labor and delivery at Rose Medical Center.