Understanding plans and benefits

 
Health insurance can be confusing. We'll help demystify the health insurance industry for you, including introducing you to some basic types of medical plans and common terms you may hear when you receive care.

If you're enrolled in a Providence plan – whether through an individual and family plan or through your employer – you can count on comprehensive coverage and genuine care.

Make the most of your benefits

There are steps you can take to make the most of your benefits.
  1. Learn the basics about health insurance.
  2. Then, take advantage of these tips to make the most of your benefits and your dollar.

Understand how your health plan and providers work together

The following example provides a general overview of what to expect when you use your health plan benefits.

You need to go to the doctor for an ongoing cough. You want to use your benefits wisely, so you decide to access care from an in-network provider (also known as a participating provider).
  1. You find an in-network provider by searching the Provider Directory. You schedule and go to your appointment.
  2. Your provider finds that you have an infection. She prescribes an antibiotic to treat your infection.
  3. You fill your prescription using an in-network pharmacy, which you found by searching the Provider Directory.
  4. The health plan pays its share of amount(s) owed to your provider and sends you an Explanation of Benefits explaining how the claim was paid.
  5. The provider bills you for the cost of services that the health plan did not cover.
  6. You pay the provider the remaining cost.

What if you didn't have insurance?

Take a look at the following two examples that compare costs without insurance to costs with insurance in a plan that has a preferred provider network:

Example 1: Sample health care cost for a sport's injury (costs are approximate):
Service Cost without insurance Cost with insurance*
Office visit: $190 $20 copay
CT scan: $1,500 $300
(you pay 20% of cost)
Emergency room: $500 $250
Radiologist: $300 $60
(you pay 20% of cost)
Lab work: $160 $32
(you pay 20% of cost)
X-ray: $150 $30
(you pay 20% of cost)
Urgent care visit: $190 $38
(you pay 20% of cost)
Total cost $2,890 $730
*This example assumes the calendar year deductible has been met and that care is received from an in-network provider. Your insurance provider pays the participating provider the balance, up to the contracted rate.

Example 2: Sample health care cost for a common virus:
Service Cost without insurance Cost with insurance*
Office visit: $190 $20 copay
Prescription for an antibiotic $50 $10 copay
Total cost $240 $30
*This example assumes a calendar year deductible need not be met for the plan to pay benefits, care received was from an in-network provider and a generic prescription drug was purchased. Your insurer pays the participating provider the balance, up to the contracted rate.

Why do I need insurance?
Seeking medical treatment for illnesses or accidents would be very expensive without health insurance. Health insurance offsets the cost of doctor bills, surgery, hospital, laboratory and x-ray fees and pharmacy costs. Take a look at two examples of the cost for care – example 1, if you're hurt in a sport injury and example 2, when you access care for a health concern, such as a viral infection.