Demystifying health insurance benefits to get the care & provider you want

Getting your health insurance to work for you can often feel like a full-time job in an unfamiliar and ever-changing landscape.

Trying to get a clear understanding of your benefits with all of the changes in insurance coverage,  the Affordable Care Act, the restructuring of insurance homes and coordinated care organization’s, can be a real challenge.

When you add into that challenge the difficulties of getting logged into a working website or reaching a live person to talk to on the other end of a customer service line, the entire process can be overwhelming.

While I know a lot about providing health care, I am not an expert on the systems that help consumers access it. This is frustrating for me, as a provider who wants to see and help as many people as I can.

So in an effort to hopefully make it a bit easier for people to access care, I am sharing what I have learned in my own process of becoming an “In Network” provider with Aetna, Blue Cross/Blue Shield, MODA/ODS, United Healthcare, Pacific Source, and CIGNA (expected in-network date January, 2014).

My hope is that what I have learned about these insurance companies may help you get the care you want, need, and deserve.

So to begin with, when you have a provider you want to see it is important to know if the provider is an “In Network Provider” or an “Out-of-Network Provider”.

‘In-Network’ providers, also called  ‘preferred providers’, are ones that have an agreement with your insurance company so that, generally, your out of pocket expenses for most visits are limited to your co-pay or by a yearly deductible.  This varies by plan, as does the amount or percent that the insurance company will pay for a given exam, procedure or type of visit.

“In- Network” providers bill your insurance and generally all you pay at the conclusion of an office visit is the amount of your co-pay or the amount your insurance won’t cover for the visit. Some visits, like well-woman exams are covered 100% by most insurance companies.

‘Out-of-Network’ providers are those that do not have an agreement with a given insurance company.  Yet for providers like myself, nurse practitioners and CNMs, many insurance plans will still provide ‘out of network’ coverage for services like well-woman exams.

This means, while the entire cost may not be limited to a co-pay, you may be able to see an “out of network” provider with your insurance company contributing some amount toward the cost.

Knowing if your insurance company provides any ‘out of network’ care to see a NP (nurse practitioner) or a CNM (certified nurse midwife) – I am both- can be a real game changer when it comes to picking a provider who you want to see.

To check how best to get your insurance company and benefits to work for you, email Nature Cures Clinic today for our new checking benefits form and while you’re at it schedule a free 30 minute meet-and-greet to get to know Sarieah Macdonald, NMNP, CNM.


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