Understanding How Healthcare Coverage Works

Healthcare claim form We understand that healthcare coverage can be complicated, and we often get questions from our members about how health plans work. We hope this post will help answer some of those questions.

Members who have questions about their coverage or claims can call Customer Service at the number on the back of their ID card.

Why do my rates change, even when I haven’t used any medical services in the last year?

Healthcare coverage is all about sharing risks and costs. By joining a plan, you become part of a “pool” of people. If you need medical care, the cost of that care is spread across the entire pool of people, who pay for it through their monthly payments.  Most people would be unable to afford a huge hospital bill, but the risk of needing such expensive care is spread across the whole pool, so you can always be confident that Premera will have the funds to meet those needs.

I don’t get sick so why do I need to bother with healthcare coverage?

None of us plan to get sick, but it can be reassuring to know that you have support and coverage if the unexpected happens and you find yourself in an accident or facing a serious illness. Even if you only visit the doctor occasionally, there are still important benefits to having healthcare coverage.

We negotiate with doctors and hospitals on behalf of our customers so that you pay lower rates for care. When you receive care, we send you an “Explanation of Benefits” to show you what the care provider charged, what we paid, and what amount, if any, you may have to pay. It also shows the “provider’s fee adjustment”. This is the discount you receive because Premera has negotiated with the hospital or doctor to reduce what they charge for that service.

Your plan also covers many preventive benefits, like screenings and vaccinations (such as flu shots), without any out-of-pocket costs to you. We want to encourage people to take advantage of these services. Preventing illness keeps our members healthy and keeps costs down for everyone.

Why do I need to use in-network doctors and hospitals?

We have a team of people who are dedicated to negotiating with doctors and hospitals to ensure that our members get safe, effective, and high-value care. Doctors and hospitals who are in our network have agreed to follow our medical policies and have signed up to specific rates for the services they provide. Our medical policies are created by doctors who review guidance from the government, national bodies, medical research organizations, and peer-reviewed medical journals.

If you use a doctor or hospital that is not in our network, there is no limit to the amount that they are able to charge for a service. This means that even when Premera pays them our contracted or “allowed” rate to perform a service or treatment, they still have the option to pursue you for additional fees. This is often known as “balance billing”. Using an in-network doctor or hospital means you will pay lower out-of-pocket costs and reduce your risk of balance billing.

More on healthcare coverage basics:

Why Do Healthcare Costs Keep Going Up?

How Do We Set Your Rates?

2 Comments on Understanding How Healthcare Coverage Works

  1. Nancy Martin // June 1, 2014 at 3:21 am //

    I haven’t received my kit and you have cashed my check. I signed up 5/1. I have a medication I have to pick up on 6/2. Can you please send Policy number since I don’t have my card? Why haven’t I received my packet? Please help.
    Nancy Martin

    • Hi Nancy. Please let us know a contact number to reach you and we can have a customer service rep to contact you asap. Thanks.

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