Health Insurance FAQs

Get answers to frequently asked questions about health insurance. You may also find our glossary useful in helping you understand health insurance terms.

Coverage and Costs
Getting Care
Plan Information
Dependent Information
Health Insurance Information

Coverage and Costs

Can I afford my own health insurance plan?

Health insurance companies offer a variety of plans to meet your healthcare needs. If you have difficulty paying for insurance, you may be eligible for a subsidy from the federal government. These subsidies help you pay for insurance if you buy a health insurance plan on the public Marketplace (also known as the public exchange).

How do I know if a certain procedure, surgery or service is covered by my health insurance plan?

Covered benefits typically include:

• Medically necessary hospital stays and surgical procedures
• Diagnostic tests
• Visits to the doctor
• Routine preventive care

Some plans include prescription drug coverage. Contact Medical Mutual to see what services your plan covers.

How do health insurance companies determine if a new medical technology or procedure is covered?

Typically when a new medical technology or procedure is available, an insurance company performs an evaluation to determine if it is appropriate for members. A new technology or procedure is often called “investigational.” After many experts do this evaluation, an insurance company decides whether or not to cover the new service.

Coverage for a new service may be limited to specific medical conditions, age groups, genders, places, types of service or diagnoses. Contact our Customer Care Center for more information about investigational services and if it’s covered under your plan.

What charges am I responsible for when I get services?

Depending on your health plan, you may have:

• A copay at each visit
• An annual deductible (possibly a family deductible)
• Coinsurance (the percentage of the doctor’s bill that you pay after you meet your deductible)
• Charges for non-covered services or charges in excess of the allowed amount (if you go to a non-network doctor or facility)

You may be charged more for services if you use a non-network doctor. Always use an in-network doctor to keep your out-of-pocket costs down.

For more information on your financial responsibility, talk to your doctor about your diagnosis and expected procedures. Then, contact Medical Mutual for information about what your plan covers.

For more information on costs, consult our article: Understanding Health Insurance Costs. To learn more about deductibles, premiums and how they are related, read "What is a deductible, and how does it affect my premium?"

Are there options to lower my prescription drug costs?

Some health plans include a tiered formulary. A formulary is a list of commonly prescribed medications selected by healthcare professionals based on clinical and cost effectiveness. Tier 1 usually includes generic prescription drugs and is the lowest cost to you. Tier 2 usually includes “preferred” brands and cost a little more. Tier 3 usually includes “non-preferred” brands, which cost even more. Some plans have a Tier 4 for specialty prescription drugs.  You could lower your copay by using a lower tier.

Ask your doctor which medication is best for your condition. With some health plans, using medications on the formulary can save you money. To request a preferred formulary drug list or to ask a question about your health plan, contact Medical Mutual.

Are there any limitations on medications that my doctor might order?

For some medications, you may have quantity limits, need prior approval or have other coverage management requirements that must be met before your prescription will be covered. Contact Medical Mutual and ask if your medication is subject to limitations or prior approval requirements.

Products that are approved by the U.S. Food and Drug Administration for cosmetic use or weight loss are not covered under most prescription benefit plans.

Getting Care

How do I get primary care services?

Primary care services, like physical exams and immunizations, are offered by providers who specialize in general medicine, family practice, internal medicine and/or pediatrics. To avoid higher out-of-pocket costs, be sure to use an in-network doctor. You can find one using our Find a Provider tool.

How do I obtain specialty services, behavioral health services or hospital services?

Talk to your primary care physician. He or she can give you advice about when to get specialty or behavioral health services, and when and where you should get hospital services.

When should I go to an emergency room, urgent care, or other facility for an immediate medical need?

Go to an emergency room if you feel you have a life-threatening injury or illness or if delaying care puts your health at risk. In these cases, don’t hesitate to go to the ER or call 911 immediately.

For minor injuries or illnesses that are not life-threatening, visit an urgent care facility. Many are open 24/7 or have extended hours. Convenience clinics are also a good option. These clinics may be located in some drug stores and grocery stores. They are staffed by nurse practitioners or physician’s assistants who can diagnose and treat many illnesses, and write prescriptions.

How do I get emergency care?

During a medical emergency, go to the nearest emergency room or, if necessary, call 911. Contact your doctor within 24 hours of the emergency to arrange follow-up care with an in-network provider.

Plan Information

Can I purchase a supplemental accident insurance with my individual health insurance plan?

Yes. To learn more, click here.

Dependent Information

Who is considered a dependent?

Eligible dependents include the policyholder's spouse and unmarried children under the dependent age limit (age 26 in Ohio), including:

• Natural children of the policyholder
• Children placed in the policyholder’s home for adoption
• Children the policyholder or spouse is the legal guardian for
• Children the policyholder or spouse has been ordered to provide health coverage for by a court
• Stepchildren (if the natural parent is also listed as a dependent of the policyholder)
• Disabled dependents* if they are:
  
  • Unmarried and under the dependent age limit
  • Primarily dependent on the policyholder for support
  • A dependent as defined by IRS income tax code
  • Covered by the contract holder's current or prior carrier

*Incapacity must have begun before reaching the dependent age limit and must be medically certified by a physician.

Can I get a policy for my child only?

Child only policies from Medical Mutual are available. A parent or guardian must sign the application for any child under age 18. If a parent wants to cover more than one child, each child requires a separate application.

What if the parents are divorced, the mother has custody and the father wants to buy health insurance for the child?

The father can add the child on his plan as a dependent. He should complete and sign the application on behalf of his child. If there is more than one child who needs coverage, the father can list all children on one application.

Health Insurance Information

How do I file a complaint about my healthcare coverage?

If applicable, you can contact your state’s Department of Insurance. Contact information is available on your state’s website, in your phone book under state agencies or by contacting Medical Mutual.

If your complaint is about a denial, decrease or termination of a benefit or service and you continue to disagree with our decision, you can file a complaint with the Department (after you have used all appeal rights).

Members of self-insured groups (other than a public employee benefit plan) should not file a complaint with the Department of Insurance. For information about how to file a complaint, contact your employer or group official, or contact the U.S. Department of Labor Employee Benefits Security Administration.