What is Insurance?

Videos and Resources to Help You Understand Insurance:

Help with Getting Insurance

How to Contact Clinics To Check Insurance Coverage

Youth-Friendly Script For Calling to Check if a Clinic Takes Your Insurance Tip: Have an insurance card or information readily available before your call

  • Call and prepare to wait on hold. (This is sad but often the case with healthcare.)
  • You: ā€œHello, my name is [Your name] and I am a [Your age]-year old patient calling to see if your clinic accepts my insurance. My insurance is [Insurance plan name]ā€
    • You may ask the following questions as well:
      • ā€œI would like to know if there are any providers that are in-network under my planā€
      • If you have any preferences for certain providers, you can mention it by saying: ā€œI am specifically interested in seeing if [Providerā€™s name] is covered under my plan.ā€ You can also often request a provider of a certain gender.
      • ā€œDo I need a referral before scheduling?ā€
      • ā€œIs my insurance accepted for [SAY TYPE OF APPOINTMENT] appointments?ā€
      • ā€œCould you please let me know of any additional costs associated with visits to this clinic/provider as I want to be aware of any out-of-pocket payments or co-paymentsā€
  • Online resources listing providers for teen check-ups:

Checking Preauthorization and Costs

Sometimes your insurance plan has to approve a service before you get it. This is called ā€œpreauthorizationā€ or ā€œprior approval.ā€ Without it, your plan might not pay for the visit, test, or procedure. Asking first can save you money and stress.

Questions to Ask Your Insurance Plan Use these as a checklist when you call:

  • Do I need approval (preauthorization) for this service?
  • How much will my plan cover?
  • What will my cost be (copay, deductible, or coinsurance)?
  • Are there limits on how many visits I can have?
  • If I need approval, how do I get it?

Tips to Make the Call Easier

  • Have your insurance card with you.
  • Know the name of the service or type of appointment youā€™re asking about.
  • Write down the name of the person you spoke with, the date, and what they said.
  • Ask them to repeat or explain anything you donā€™t understand.
  • If possible, ask for a confirmation email or letter.

You can copy this into your notes app before calling:

ā€œHi, my name is [Name]. Iā€™m on your health plan and Iā€™m thinking about getting [service/test/visit]. Can you tell me:

  • Do I need approval first?
  • If yes, how do I get it?
  • How much will my plan cover?
  • What will my cost be?ā€

 

Glossary with Helpful Terms

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Premium

  • Formal: The amount you pay (usually monthly) to maintain your health insurance coverage, regardless of whether you use health services.
  • Youth-Friendly: The monthly bill you pay to keep your health insurance active.

Deductible

  • Formal: The plan year amount a person pays for health services, outside of their premium and copays/co-insurance, before insurance starts to help.
  • Youth-Friendly: The total plan year amount you have to pay (not including your premium or copays/co-insurance) before your insurance starts paying too.

Copay (Copayment)

  • Formal: A fixed amount a patient pays for a health service.
  • Youth-Friendly: What you pay out of your own pocket (like $10 or $20) when you see a doctor.

Coinsurance

  • Formal: The percentage of a covered health care cost you pay with the insurance covering the rest.
  • Youth-Friendly: The part of the bill (like 20% or 30%) you pay.

In-Network/Out-of-Network

  • Formal: Health care providers who are (or are not) contracted with your insurance plan.
  • Youth-Friendly: If a clinic is ā€œin-network,ā€ your insurance will help pay more of the cost.

Explanation of Benefits (EOB)

  • Formal: A statement from your insurance company explaining what medical treatments or services were covered, the cost paid, and any amount owed by you.
  • Youth-Friendly: A paper or email that breaks down what the doctor charged, what your insurance paid, and what you still have to pay.

Preauthorization (Prior Authorization)

  • Formal: Approval from your health insurance plan before receiving certain medical services, treatments, or prescriptions to confirm coverage.
  • Youth-Friendly: Permission your insurance company sometimes has to give before you can get certain care or medicine.

Maximum Out-of-Pocket Limit

  • Formal: The most you will pay for covered health care in a plan year, including deductibles, co-pays, and coinsurance. After you reach this limit, your insurance covers 100% of covered services.
  • Youth-Friendly: The highest amount youā€™ll have to spend in a year before your insurance pays for everything.

Health Maintenance Organization (HMO)

  • Formal: A type of health insurance plan that requires members to use in-network providers and typically needs referrals from a primary care provider for specialist care.
  • Youth-Friendly: A plan where you have to see doctors in your insuranceā€™s list and usually get permission from your main doctor before seeing a specialist.

Preferred Provider Organization (PPO)

  • Formal: A type of health insurance plan with a network of preferred providers but allows members to see out-of-network providers at a higher cost and without referrals.
  • Youth-Friendly: A plan where you can see almost any doctor you want, but itā€™s cheaper if theyā€™re on your insuranceā€™s list.

Medicaid (Medical Assistance in MN)

  • Formal: Minnesotaā€™s version of the federal Medicaid program, offering free or low-cost health coverage to eligible low-income residents.
  • Youth-Friendly: Free or cheap health insurance from the state for people who qualify based on income.

MinnesotaCare

  • Formal: A state health insurance program in Minnesota for residents who earn too much for Medical Assistance but still have low or moderate incomes.
  • Youth-Friendly: Cheaper insurance from the state for people who donā€™t qualify for free insurance but still canā€™t afford regular plans.

Marketplace / Exchange

  • Formal: An online platform where individuals can compare, choose, and purchase health insurance plans, often with income-based subsidies.
  • Youth-Friendly: A website where you can shop for and buy health insurance, with discounts if you qualify.

Plan Year / Coverage Period

  • Formal: A 12-month period of benefit coverage under a health plan.
  • Youth-Friendly: The 12-month period health insurance lasts before it resets.

Referral

  • Formal: An order sent from a primary care provider to another provider for care they can not provide.
  • Youth-Friendly: When your main doctor sends you to another doctor because they canā€™t give you the care you need themselves.