Parent Newsletter April 2025
expenses. Here are some of the key terms to understand.
Premium – The amount you pay each month to have health insurance. This is a fixed cost, whether you use your insurance or not. The lower your premium, the more you might pay in other costs like copays, deductibles, or coinsurance.
Deductible – The amount a person or family must pay for medical care and prescriptions before insurance starts helping cover the costs. Many plans cover some services, like routine health care screenings, check-ups, and vaccines before meeting the deductible.
Copayment (Copay) – A set amount you pay for a medical service or supply. The amount of the copay depends on the service so you may have different costs for things like prescriptions, lab tests, and even doctor’s visits.
Coinsurance – The percentage of the medical bill you pay after the deductible has been met. If your plan has 20% coinsurance for a service, you pay 20% of the bill and insurance pays the rest.
Maximum out-of-pocket cost (MOOP) – The most you would pay in a plan year for covered services. The deductible, copayment, and coinsurance all count toward the MOOP. When that limit is reached insurance pays 100% of covered services for the rest of the plan year.
The out-of-pocket limit doesn’t include:
• Your premium
• Anything you spend for services your plan does not cover
• Costs above the allowed amount for a service a provider may charge
Finding Out What Is Covered
Understanding what your health insurance can help you make the most of your benefits. Every plan is different, so you must review the details before you need care. From doctor visits to prescriptions, knowing what’s included will help you plan ahead and save money. Here are some simple steps to check what your insurance covers and how much you’ll need to pay.
Check Your Summary of Benefits and Coverage (SBC)
Every health insurance plan has a Summary of Benefits and Coverage (SBC) document. This simple chart lists what medical services are covered, how much they cost, and what you will have to pay. You can find this document:
• On your insurance company’s website
• In the paperwork you received when you signed up
• By calling your insurance company and asking for a copy
Check Your Full Insurance Policy for Details
The full insurance policy or member handbook has all the details about what’s covered and what’s not. It explains:
• Which doctor visits, tests, and treatments are included
• What types of care need approval from the insurance company first
• Which hospitals and clinics are part of the plan’s network
Check the Provider Network
Health insurance plans have a network of doctors, hospitals, and specialists that they work with. If you see a doctor inside the network, you’ll pay less. If you go outside the network, you might have to pay more or even the full cost. Networks can change, so doublecheck your health plan network by:
• Visiting your insurance company’s website and search for in-network providers
• Calling your doctor’s office and ask if they accept your insurance
Find Out About Prescription Drug Coverage
If you regularly take medication, check the plan’s formulary (a list of covered medicines). Some medicines cost more than others, and some might need approval before the insurance covers them. You can:
• Look at your insurance company’s website for a list of covered drugs
• Ask your pharmacy if your medication is covered
Call Customer Service
If you’re still unsure, call the customer service number on the back of your insurance card. They can tell you if a specific service, doctor, or medicine is covered.
By checking these things, you’ll know exactly what your insurance covers and avoid surprise costs!
Using Your Insurance
Step by Step: What happens when you use your insurance:
1. You give your provider your insurance card when you seek medical care. Learn more at Understanding Your Insurance Card
2. You pay the provider any co-payment required by the plan
3. Usually, the provider bills the insurer
4. After your visit, your insurance company will send you an Explanation of Benefits (EOB). Don’t worry—this isn’t a bill! It just shows what your doctor charged, what insurance covered, and what you might
owe. Learn more at Understanding Your Explanation of Benefits
5. You will most likely get a bill separately from the provider. You pay your share of the bill
If you think a service should have been covered but wasn’t, here’s what you can do:
• Call your insurance company (the number is on your card or their website). Ask them to explain the charge
• If you have questions about your rights or need help understanding insurance billing or coverage, call the Oregon Division of Financial Regulation to speak with a consumer advocate free of charge at 888-877-4894 (toll-free) or email DFR.InsuranceHelp@dcbs.oregon.gov
How to Pick the Best Plan for Your Family
Choosing the right health plan means making sure your family gets the care they need— without breaking your budget. Think about your regular doctor visits, medications, and any special care needs before picking a plan.
Think About Your Family’s
Healthcare Needs
Ask yourself these questions:
• How often do family members visit the doctor?
• Does anyone have a chronic condition that needs regular treatment?
• Are there specific doctors or specialists you want to keep seeing?
• Do you take medications regularly?
Compare Costs
When choosing a plan, it’s important to balance monthly costs with what you might pay when you need care. A lower monthly premium might seem like a great deal, but if the deductible is high, you could pay more out-of-pocket when you need medical care. If you’re worried about high medical costs, a plan with a lower maximum out-of-pocket cost may be worth it. Find a balance that works for your budget.
Not sure where to start?
• See what you may be eligible for at OregonHealthCare.gov/WindowShop
• For Oregon Health Plan in Benton, Lincoln & Linn Counties visit ihntogether.org
• Free help is available, too! Find an expert in your area at OregonHealthCare.gov/ GetHelp
• If choosing a work-provided plan, contact your employer
• Understanding your health insurance plan can be a bit overwhelming and confusing. These resources can help you make sense of your benefits, make the most of your coverage and keep track of the information you need. Learn more at Navigate Your Coverage.
Now that you have a better understanding of health insurance, you will have the confidence to:
• Make sure your plan covers your regular healthcare needs, includes your preferred doctors, and fits your budget.
• Use online tools to compare plans or contact customer service for help.
• Review your current health insurance plan or explore new options based on your family’s needs.
Health insurance can feel complicated, but with these tips, you can make the best choice for your family’s needs. If you have any questions, don’t hesitate to contact your insurance provider or reach out for free expert assistance.
541-917-4884, pollywog@linnbenton.edu
