Ultimate Guide To Understanding Your Health Insurance

Ultimate Guide To Understanding Your Health Insurance

If you’re intimidated by health care don’t worry because you’re not alone.

There are questions like:

  • How do I obtain insurance?
  • How do I use my insurance card?
  • Who will take my insurance?
  • How do I find a doctor?
  • Does this doctor treat my condition?
  • How much will a visit cost?

So on and so forth.

Because of THOSE questions and THAT confusion surrounding health insurance we took the liberty of  put together this monster resource titled Ultimate Guide To Understanding Your Health Insurance.

Everything from understanding your insurance card, scheduling doctors appointments, even  making sense of deductibles and out-of-pocket maximums will be explained.

Again if the mere mention of  “health insurance” causes an uneasy feeling, simply take a deep breath…

Grab your favorite beverage…

Find a cozy reading nook…

And read on as we break down everything you need to know about health insurance into small easy to understand chunks.

Using Your Insurance Card 

It’s important that you take your health insurance card with you everywhere you go. Whether it’s your doctor’s office, the pharmacy, a lab for medical tests or even a hospital visit, make sure to keep your insurance card handy.

Your insurance card will help you with the cost of all of the aforementioned health services. After all that’s why you purchase health insurance in the first place!

If your phone has a camera it’s a good idea to take a picture in the event you do forget your insurance card. If you can’t take a picture, write down the information on your insurance card. If you lack a pen, at least remember the exact name of your insurance plan.  Knowing the name of your insurance plan will help a health provider if they need  to call your insurance company to verify your coverage.

Below are examples of insurance cards. We’ve provided examples of a Texas Medicaid Card, Medicare and an example of what a private insurance card could look like.

Texas Medicaid Card

understanding your medicaid card

Medicare Card

understanding your medicare card

Example of Private Insurance Card

When calling you insurance plan, representatives will use the information found on these cards to identify you and your coverage. For this reason it’s important be ready with your card when contacting your insurance company.

Now that you have a general understanding of when your card is needed and how it looks we’ll next discuss selecting a primary care provider.

Selecting a Primary Care Provider

Having health insurance doesn’t give you the luxury of seeing any doctor.  You need to choose a doctor who is “in your network”.  Being “in your network” simply means the doctor accepts your insurance.

Nearly all health insurance plans have a network of providers. Your insurances network is comprised of health care providers who have agreed to accept your health insurance.

The first medical decision you should make with your health insurance is selecting a primary care provider or a PCP. Your PCP is the one who treats you when you become ill.

If you select a provider who is “out of network” you may still be able to see them although you will pay a higher cost as opposed to a provider who is “in network”.

The reason being is that “out of network” provider has not agreed to accept your health insurance. Because of this reason it’s wise to stay “in network” when selecting providers.

How To Find A PCP “in network”

The most important factors to consider when choosing a PCP are:

  • If the PCP is “in network”?
  • If the PCP is accepting new patients?

Once these two questions are answered you can then consider other options like:

  • The PCP’s hours? Are they open weekends and evenings?
  • Would you prefer a man or woman?
  • Does ethnicity matter?
  • What area of the city?
  • Maybe you prefer a doctor who speaks a certain language?
  • Do they have a specialty?

Once you know what type of doctor you are seeking you can find them in one of two ways:

  • Contact your health plan
  • Search your health plan’s website

Before making a decision to visit this PCP be sure to contact them and again ask whether they are “in network” and accepting new patients.

Calling Your Health Insurance Plan

Now that you know what type of PCP you want, it’s time to call member services.

When contacting member services they will typically ask for your name and member ID. The member ID can be found on your insurance card.

Note: The number to member services is typically on the back of your insurance card.

Once member services verifies your coverage you can then explain to them your reason for calling which is to find a PCP.

Provide member services with details like locations, gender, specialty, language and other options of your idea PCP. Member services will then search their database and provide you with a handful of names and telephone numbers for you to independently follow up with.

Calling Doctors

You’ve obtained a listing of PCP’s so now the next step is contacting them.

When you reach the PCP’s office again ask if they are in your health plan’s network and if they are accepting new patients.

If you prefer a specific language pay attention to the receptionist’s communication style and also ask if the PCP speaks a certain language. This will be one of the most important relationships in your life, so you want to be sure that you are able to effectively communicate with not only your PCP, but office staff.

If there is any indication that this PCP won’t be a good fit move on to the next provider on your list.

Ask friends or co-worker’s if they are familiar with anyone on your list. Also ask if they can recommend a good PCP. If you can’t find anyone to provide a recommendation search an online review site like Health Grades.

Making Your First Appointment

When you’ve finally found the perfect PCP it’s now time to make your first appointment.

Even if you aren’t sick, schedule an appointment with you PCP right away.  If there are problems with this new PCP it’s important that you learn about these issues as fast as possible. Not to mention if you’re sick and dealing with these unforeseen issues it will make your experience that much worse.

We’ve mentioned this before and we’ll mention it again. Ask the receptionist if they accept your health insurance plan. Read the full name of your health plan slowly to ensure they do accept your health insurance.

If they do not accept your health insurance simply contact the member services number (on back of your insurance card) and ask for a listing of PCP’s who accept your insurance.

If they do accept your insurance it’s now time to plan for your first appointment.

Continue reading to learn more about preparation for your initial PCP visit.

Plan For Your First PCP Appointment

Typically PCP appointments only last from 10-20 minutes. Because of this limited timeframe it’s important to be prepared so you’re able to get all your questions answered in one visit.

To accomplish this task, the first thing you’ll need to do to make a list of all your medications. Diabetes, hypertension, anti-depressants, basically any medication you take jot it down on a piece of paper as well as the dosage.

As you write down the medications you take also note your medical conditions. Again if you have a diagnosis of diabetes, hypertension or depression make note of these things. Many times when visiting a PCP we forget a few medical conditions/medications that we take. Writing these things down seems obvious although don’t overlook this step. Doing so you run the risk of “going blank” when speaking with your new PCP.

Note: If you have a smart phone consider downloading the Evernote app. This is one of the easiest ways to create notes and easily organize them.

Should your PCP scheduled medical testing prepare for this as well.  This could mean fasting prior to your visit if your PCP requires you to.

Lastly, make time to meet with your PCP. Avoid making any other plans that may overlap your initial PCP appointment.  You’ll be meeting your PCP for the first time so they may want to spend extra time going over your current conditions and past medical history.

Your First PCP Visit

During your first visit dress in comfortable clothing. Wear comfortable footwear and if you’re cold natured bring a light sweater in the event that the office is cold.

In addition to dressing comfortable also bring a book or anything worth reading if your wait is 20 minutes or more.

You’re meeting with your PCP for the first time so don’t be afraid to ask questions. Communication with your PCP should be a two way street. If you need your PCP to repeat something say so. If you need them to spell out a prescription say so. It’s your right to have these questions answered because your insurance is paying for this right.

Should your PCP schedule lab testing it’s also appropriate to ask if you will have to pay?

Again if there are any questions that you have for your PCP get into a habit of asking them right away.

Following Up For Lab Results

For results of lab testing your PCP or the lab will contact you. If you don’t receive a follow up in 2-3 weeks simply pick up the phone and call your PCP.

Picking Up Prescriptions

When picking up prescriptions one of the first questions you should ask is if the medications are covered by your insurance plan. If they are not covered call your PCP and ask if there is a less expensive alternative.

Note: Generic medications are typically less expensive than brand-name drugs. Stores like Wal-Mart with their own pharmacy offer cheaper prescription medications, so be sure to consider them when filling prescriptions.

Next be sure that you understand the directions on your prescription bottle before you leave the pharmacy. If there is any doubt about the directions ask your pharmacist. They are trained to answer nearly any question you can think of. In the event they can’t answer your question contact your PCP.


Some health insurance plans require referrals before they will pay the costs. If your PCP refers you to a specialist be sure that they submit this referral to you health plan or risk paying a greater portion for services.

If there is any question that the specialist is “out of network” contact your health insurance’s member services and ask. If the specialist is indeed “out of network” contact your PCP and request an “in network” specialist.

Changing Your PCP

After visiting your PCP for the first time consider the experience? How did you feel? Was it memorable?

If not change your PCP.

As we mentioned earlier this will be one of the most important relationships in your life. You should feel comfortable visiting with you PCP and if this is not the case again, change your PCP.

You can find a new PCP by contacting member services and simply requesting a new one.

Medical Emergencies

Before briefly explaining what you should do in a medical emergency, let us first provide some examples of actual medical emergencies.

  • Chest pains
  • A car accident
  • Broken bones
  • Suicidal or Homicidal Ideations
  • Difficulty breathing
  • Non stop vomiting

All of these are situations where you will want to either visit the nearest ER or contact 911.

If your situation is less severe continue reading to learn about treatment options for non-medical emergencies.

Non-Medical Emergencies

If you come down with a minor illness like a common cold, nausea,  headache or rash consider the following two options:

  • Contact a 24 hour nursing line like Nurse Health Line (713.338.7979 or 1.855.577.7979) or Ask Your Nurse (713.633.2255). These lines are staff 24/7 by nurse who can provide advice and guidance on when and where to go for treatment.
  • Visit an urgent care clinic. If you choose this option be sure to select an urgent care “in network”. For a listing of Houston area urgent cares click HERE.
  • Contact your PCP.

When contacting your PCP they will either schedule an appointment to treat your illness or in some cases they will prescribe medications for you to pick up at a pharmacy depending on your symptoms.

Costs Of Health Insurance

In this section we’ll discuss the 4 types of costs you pay for health insurance.


A premium is a payment made each month for your health insurance. You’ll pay this premium for the entire year that you have health insurance.

Your premium can increase, decrease or stay the same each year. During your health insurance plan’s open enrollment period consider alternative plans especially if they offer the same amount of care for less cost.


A deductible is a certain dollar amount that you must pay before your health insurance plan begins to pay all or most of your costs.

Here’s an example:

Your health insurance plan that comes with a $500 deductible.  You will need to pay $500 worth of medical services (PCP visits, lab testing, prescription medications, etc) before your heath insurance plan will help with the costs. After your deductible, $500 in this example, is met then your health insurance plan will pay all or most of the costs.


Your co-payment is a fixed cost associated with certain medical services.

The most common co-payment would be a doctor’s visit which could be $15 per visit. For prescription medications your co-payment could be $5 per bottle.

Often times you will find the cost of your co-payments listed on your insurance card.


The last type of cost you could pay for health insurance is called co-insurance. Once you pay your health insurance’s deductible, you could pay a co-insurance cost in some situations.

Co-insurance is a percentage (%) payment of the total cost of a health service.  Your co-insurance could be a 20% payment for a certain medical services while your insurance plan pays the remaining 80%.

Here’s a better example:

You’ve paid your yearly deductible of $500. From this point on your insurance pays all or most of your health care costs. The only cost your health plan won’t cover is a co-insurance cost.

Let’s say you…let’s say SOMEONE ELSE steps down from a curve and hurts their ankle.  They visit their doctor and he decides that an X-ray is needed. Later that month the individual would get a bill for $20.  The x-ray cost $100. You paid $20 (20%), while your health insurance plan paid $80 (80%).

Note: In the example above if you hadn’t met your annual deductible then you would be billed the total $100 cost of the x-ray.

Double Note: Typically the lower your monthly premium is the higher your co-insurance.  The reverse is also true. The higher your monthly premium is the lower your co-insurance  is.

Annual Out-of-Pocket Maximum

The out-of-pocket maximum sets a limit on the amount of money you pay for health insurance. This protects an individual from the health care costs of a major illness or accident.

As of 2016 the most an individual would pay is $6850. The most a family would pay is $13700.

Once the out-of-pocket maximum is paid the health insurance plan pays for health care for the remainder of the year.

Your Health Care Costs

All health plans vary in cost. Some have higher premiums, co-pays and co-insurance costs. Others have lower deductibles and out-of-pocket maximum costs. To learn about the exact cost of your health care or if you have questions regarding any of the other topics discussed in this ebook simply contact your health plan’s member services number and ask.

Also if you need more community resources like this, visit HoustonCaseManagers.com for quick and easy how-to’s on connecting your clients or yourself to helpful local resources.

Bonus: Download this Ultimate Guide to Understanding your Health Insurance Click here to claim yours.

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