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Have you ever looked closely at your health insurance card? Taking good care of yourself means having a thorough understanding of its benefits and how to access them. this is the first part of a series on understanding health insurance… and it starts with your card!

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what’s on the front of your insurance card?

The front of your insurance card has specific information about you or your family (also called “dependents”). Your doctor’s office uses it to file claims, and you can also use it to understand what’s covered (or not) and how much of the cost you’ll pay. here’s more information about each item you’ll see:

1. your health insurance company. there may be one or two names in the list. For example, you can say Aetna, Humana, or Blue Cross, which is the major health insurance company. But then there could be another name like First Doctors or Doctors of the Hill, which is the Preferred Provider Network or Accountable Care Organization (ACO) that your health insurance company has a contract with.

2. subscriber or member ID. the name and ID of the primary policy holder, which can be you or sometimes your spouse.

3. dependents the name and identifications of the other persons covered in the insurance plan.

4. group or issuer. a unique ID for the employer that pays for the plan you have. identifies your benefits and is used by the doctor’s office to submit claims, along with your member ID.

5. effective date. the start date your insurance was activated.

6. plan. this is the type of benefit plan you have. there are so many types: you could be part of an hmo, ppo, or hdhp (high deductible plan). Knowing the type of plan you have is important because it affects whether you need prior authorization to see doctors, which ones are “in-network,” and how much of the cost you share.

7. pharmacy benefits (rxbin). this is the member ID for your pharmacy benefits, which are administered through a pharmacy benefits manager (pbm). examples include cvs/caremark and express scripts. To make it even more confusing, some health insurers have their own PBMs! Essentially, this is the group that helps determine if your drugs are covered and what your share of the cost is.

8. pcp. This is the name of your Primary Care Physician. If you have an HMO plan, you have a defined PCP that needs to refer you for specialty care, so make sure the correct PCP is on the list.

See also : Is there a penalty for not having health insurance in 2021?

9. copay although additional costs can sometimes come into play, the copay is usually your upfront share of the cost of appointments. There are usually different copays for a checkup, urgent visit, emergency visit, or hospital stay. Note that this is different from your deductible – this is not listed on your insurance card because it varies for different services. You may also have to pay a percentage of the cost, such as 20 percent, depending on whether or not you see an in-network provider. To understand your deductible and share of cost, you’ll need to check your insurance website or employer’s benefits page.

A sample of the front of a health insurance card: can you identify each item?

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what’s on the back of your insurance card?

The main purpose of the reverse side is to provide contact information in case you or your provider have questions about your benefits, need the name of a preferred provider, or wish to file a claim. It’s often easier to take care of these tasks online these days, but if you prefer to communicate by phone, here are some key numbers to look for:

1. customer or member service number. This is the number you call when you have questions about your health insurance. typical questions are about what services are covered, what your share of the cost is, or which provider is “in-network.”

2. mental/behavioral health number. mental health benefits, such as therapy, psychiatry, and group treatment, are “excluded” from your health insurance and are provided to other groups, such as united behavioral health and optum. that is why there is a different number to call for these services.

3. pharmacy services. Pharmacies often use this number to confirm whether or not a drug is covered by your plan, but you can also call yourself. This number goes to your pbm, a company your health insurance company partners with, which determines your drug coverage.

4. provider’s customer service. This is the number your doctor’s office calls to verify your coverage.

5. health insurer address for claims. Even though your card has this address for claims, there are usually paperwork and specific rules about claims. The best way to file a claim is to first check your health insurance website for the correct form.

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What health care is usually covered by your “insurance”?

Most employers offer health, pharmacy, mental health, dental, vision, and disability coverage. but this attention is usually managed by different groups. For example, your health insurer typically covers health care, mental health, and pharmacy benefits, while other companies typically manage your dental, vision, and disability benefits. you must have other cards or member IDs for those benefits.

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Who can help you navigate all of this?

If you’re confused, don’t worry: you (or your spouse) should have an employee benefits office and a website that can help you understand your benefits. It can be hard to know who to call in every situation, but the people who benefit from the employer are there to help. many companies now have health navigators who can also help you on an individual basis.

Stay tuned for the next part of this series, when we’ll talk about how much you’ll pay when you get care.

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about the authordr. Caroline B. Jasik is an adolescent and young adult specialist who focuses on preventative health and wellness. she is especially interested in preventing future chronic health conditions by encouraging patients to adopt healthy habits. dr Jasik practices medicine in San Francisco and also works at Mango Health as Vice President of Medical Outcomes.

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Do you have any questions for a future medical education publication?Tell us what interests you at [email protected]

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more from our medical education series:– what you can do to prevent medical errors- how important is the attitude of the doctor at the bedside?- navigating a new diagnosis of chronic disease

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Posts on this blog are for information only. They are not intended to take the place of a relationship with your physician or other health care provider, nor do they constitute medical or health care advice of any kind. Information in these publications should not be acted upon without regard to primary source material and professional input from health care providers themselves.

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