Health insurance can be difficult to understand. In this article, we’ll go over some of the terms you may come across related to insurance, talk about how to better understand your insurance benefits, and how you might go about getting health insurance. If you’d like to learn more about how you can use your insurance with FOLX, read this article.
Let’s first go over some basic insurance terms and definitions. This can help you better understand the terms you might see in your insurance policy.
1. Health insurance premium: This is the cost you pay monthly for your health insurance.
2. Summary of benefits and coverage: An online or paper booklet of your health insurance benefits, in plain language. It is required that insurance companies make a summary of benefits and coverage available to you.
3. Copay: A set amount you pay at the time of a visit or procedure. With copays, your health insurance plan covers most of the cost, and the copay is your part of the payment. Different services (like preventive care visits or mental health services) can have different copay costs.
4. Coinsurance: Coinsurance is similar to a copay, but uses percentages rather than a set cost, so you and your insurance company both pay a portion of your healthcare costs according to a predetermined percentage. For example, let's say you have a coinsurance rate of 20%. If you have a medical bill for $100, you would be responsible for paying $20 (20% of the total cost). Your insurance company would pay the remaining $80. Coinsurance is the percentage of the service fee that you're responsible for paying. Like copays, different services can have different coinsurance costs.
5. Deductible: A deductible is a set amount of money that you have to pay for health care out of your own pocket before your health insurance starts covering your medical expenses. Not all insurance plans have deductibles.
6. Prior authorization: A request for authorization from your insurance company before treatment is provided. For example, if you need surgery, your doctor may need to get prior authorization from your insurer before surgery is scheduled.
7. Cash pay rate: Cash pay rates are the amount you pay out of pocket for health services at the time of service. If you don't have health insurance or if your employer doesn't offer coverage, you can pay out-of-pocket for services, at the time of service.
8. In-network: In-network insurance means that you get certain benefits and cost advantages when using healthcare providers and facilities that are part of your insurance plan's network. When using doctors, hospitals, or clinics that are in-network, you typically pay less because your insurance plan has negotiated lower prices with these providers. In-network care is usually more affordable and convenient compared to out-of-network care, where the insurance plan may cover less or require higher out-of-pocket costs.
9. Out-of-network coverage: Note that some health insurance plans do provide out-of-network coverage. Out-of-network coverage means you can receive medical services from healthcare providers who are not part of your insurance plan's network. While this option provides more flexibility in choosing doctors or facilities, it often costs more. Insurance plans typically cover a smaller portion of the expenses for out-of-network care, which means you may have to pay more. Additionally, some services may not be covered at all when obtained out-of-network.
Understanding your insurance benefits
When you are enrolled in insurance, you will have access to a benefits guide, often called a summary of benefits and coverage, or a benefit booklet. Your benefits guide is a summary guide of what benefits come with your insurance plan. When you go to facilities that accept your insurance, typically “in-network” providers, you can usually expect insurance to pay a portion of the costs. (You can still see a clinician here at FOLX even if we are not in-network with your insurance; it just means that your insurance will not contribute to the cost of the visit.)
Understand the kind of care you are getting. Many policies have different coverages for mental health, primary or preventive care, and specialist visits. (Most visits at FOLX are considered primary care visits, except for our mental health offerings.) The amount you will pay for each visit type (also called a copay or coinsurance) will be listed in your benefits summary. You can call the number on the back of your insurance card to clarify any questions. Additionally, the number to call or contact email for your benefits provider should be listed in your benefits booklet.
HSAs and FSAs
You can use a HSA (Health Savings Account) or FSA (Flexible Spending Account) if your insurance plan offers it. HSA’s and FSA’s are types of savings accounts you can use to pay for certain medical expenses. You contribute money to the account before taxes are taken out of your paycheck. Then, medical expenses, such as doctor's visits, therapy, prescriptions, and certain medical procedures, can be covered by these funds.
(At FOLX, the membership fee is not usually reimbursable by a HSA or FSA. However, you may be able to use your HSA or FSA to pay for clinician appointments, prescription medications, and other medical costs–depending on your HSA or FSA plan.)
How to get insurance
You can get insurance either through your employer or privately. Getting private insurance is typically more costly than taking the insurance offered by your employer, if that is an option for you. This is because your employer typically covers a portion of the health insurance premium.
To get insurance coverage through your employer, you can sign up during the open enrollment period for benefits at your workplace. Talk with your company or human resource department if you are interested in company-provided benefits.
Using insurance at FOLX
At FOLX, insurance can be used to cover visits, labs, and medications depending on your insurance plan and coverage. Check out what insurance plans are in-network with FOLX here, and keep an eye out because we’ll be rolling out more soon. For more detailed information about how to use insurance at FOLX, check out this article. We can’t wait to take care of you!
FOLX Health is the first digital healthcare company designed by and for the LGBTQIA+ community. Our services include virtual primary care, gender-affirming hormone therapy including estrogen and testosterone (HRT), mental health care, sexual and reproductive health care, preventive care, and fertility consultations. FOLX memberships give you access to LGBTQIA+ expert clinicians, peer support, thousands of LGBTQIA+ resources, and more. Whether you’re lesbian, gay, bisexual, transgender, queer, gender non-conforming, or nonbinary, you can find LGBTQIA+-specialized health care that helps you meet your wellness goals. FOLX Health is health care that's queer all year. Get all the benefits of becoming a FOLX member and sign up today!