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1. How quickly can you be seen by a private consultant? 2. Will you need to see your GP first? 3. Does the insurance provider offer access to a GP who can refer you if you need specialist help? 4. Are there limits to the amount of cover you can claim each year? 5. Does the provider offer ongoing treatment for mental health issues? 6. Will you get a discount on cover if you insure your family?
The best health insurance plans will make it really clear what is and isn’t included in your cover. Most policies don’t cover:
Learn more about health insurance exclusions.
How does private medical insurance work?View guide
Bupa health insurance covers all the things we’ve discussed above but there are also some things we do a bit differently.
Bupa health insurance is provided by Bupa Insurance Limited. Registered in England and Wales No. 3956433. Bupa Insurance Limited is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. Arranged and administered by Bupa Insurance Services Limited, which is authorised and regulated by the Financial Conduct Authority. Registered in England and Wales No. 3829851. Registered office: 1 Angel Court, London, EC2R 7HJ.
Your health insurance policy is an agreement between you and your insurance company. The policy lists a package of medical benefits such as tests, drugs, and treatment services. The insurance company agrees to cover the cost of certain benefits listed in your policy. These are called “covered services.” Your policy also lists the kinds of services that are not covered by your insurance company. You have to pay for any uncovered medical care that you receive. Path to improved healthHow do I know which services are covered?If you already have an insurance plan and want to keep it, review your benefits to see which services are covered. Your plan may not cover the same services that another plan covers. You should also compare your plan with those offered through the Health Insurance Marketplace. The Health Insurance Marketplace is a service that helps you shop for and compare health insurance plans. It is operated by the federal government. Essential Health BenefitsMost insurance plans will cover a set of preventive services. This does not mean they are free. You may still need to pay deductibles, copayments, or other out-of-pocket costs. These preventive services include shots and certain health screenings. If you buy a plan through the Health Insurance Marketplace, your insurance will cover the preventive services. It will also cover at least 10 essential health benefits required by the Affordable Care Act (ACA). All private health insurance plans offered in federally facilitated marketplaces will offer the following 10 essential health benefits (EHBs):
State-run marketplaces are also required to offer 10 EHBs, but the list of benefits may differ from those offered by federally facilitated marketplaces. Plans may offer additional coverage. Preventive ServicesPreventive services can detect disease or help prevent illness or other health problems. The types of preventive services you need depend on your gender, age, medical history, and family history. All plans from the Health Insurance Marketplace must cover the following without charging a copayment: For all adults:
For pregnant women or women who may become pregnant:
Other covered preventive services for women:
Preventive health services for children (and when they should be provided) depend heavily on age. To learn more about what services may be covered for your child, see a complete list appropriate for his or her age on healthcare.gov. What is a medical necessity? Is that different from a covered service?Keep in mind that a medical necessity is not the same as a medical benefit. A medical necessity is something that your doctor has decided is necessary. A medical benefit is something that your insurance plan has agreed to cover. In some cases, your doctor might decide that you need medical care that is not covered by your insurance policy. Insurance companies determine what tests, drugs and services they will cover. These choices are based on their understanding of the kinds of medical care that most patients need. Your insurance company’s choices may mean that the test, drug, or service you need isn’t covered by your policy. What should I do?Your doctor will try to be familiar with your insurance coverage so he or she can provide you with covered care. However, there are so many different insurance plans that it’s not possible for your doctor to know the specific details of each plan. By understanding your insurance coverage, you can help your doctor recommend medical care that is covered in your plan.
Things to considerOther costsYour insurance company may ask you to pay for some of the care you receive. This is often called cost sharing because you share or pay some of the costs, and your insurance company pays the rest. There are different types of costs that you could pay. These include: Copayment: Sometimes this is called a “copay.” This is usually a set amount you pay for a visit, test, or medication. Copays are usually lower for family doctors than specialists. Deductible: This is the amount of money you need to pay each year before the insurance company will cover all the remaining costs. It is often referred to as “meeting your deductible.” If you are healthy and don’t use healthcare often, having a high deductible and low monthly cost for insurance may make sense. However, if you become sick, then your costs may be higher. Coinsurance: After you have met your deductible for the year, some insurance companies still require coinsurance. This is the percent of the cost that you will still pay for some services. All of this can be confusing. It is important to know what your coverage plan offers before you sign. Call your insurance company if you don’t understand, or speak with your doctor for answers to your questions. What happens if my doctor recommends care that isn’t covered by my insurance?Most of the things your doctor recommends will be covered by your plan, but some may not. When you have a test or treatment that isn’t covered, or you get a prescription filled for a drug that isn’t covered, your insurance company won’t pay the bill. This is often called “denying the claim.” You can still obtain the treatment your doctor recommended, but you will have to pay for it yourself. If your insurance company denies your claim, you have the right to appeal (challenge) the decision. Before you decide to appeal, know your insurance company’s appeal process. This should be discussed in your plan handbook. Also, ask your doctor for his or her opinion. If your doctor thinks it’s right to make an appeal, he or she may be able to help you through the process. Questions for your doctor
ResourcesU.S. Centers for Medicare and Medicaid Services, HealthCare.gov: Preventive health services U.S Centers for Medicare and Medicaid Services, HealthCare.gov: What Marketplace health insurance plans cover |