Insurance 101

Get information on basic insurance terms and be informed about how to navigate insurance as an LGBTQIA+ person.

October 28, 2024
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Let’s face it. Insurance is confusing. It can be especially difficult for folks in the LGBTQIA+ community who face even more challenges within the healthcare system. The best thing you can do is be informed and educated about your insurance plan and your rights so you can ask the right questions to get the information you need.

In this article, we’ll go over the insurance terms you should know, talk about how to find information on your specific plan, provide tips on how to advocate for yourself with your insurance, and let you know the ways in which FOLX can support you. 

Many folks get insurance through their employer, but if that’s not an option for you, you can check out HealthCare.gov for more options. You can sign up for a private insurance plan or Medicare or Medicare if you are eligible.

Here at FOLX, we are in-network with select insurance plans, with more being added all the time! Check out how insurance works with FOLX in this article.

Glossary of Terms

When we talk about insurance, there are many terms that you should know. These can help you better understand how insurance works, what your plan means, and how to talk about insurance.

Premium

This is the amount that you pay monthly for your health insurance.

Deductible

This is the amount you have to pay out-of-pocket before your health insurance starts covering your medical expenses. Your deductible resets each year, usually on January 1, but there are some insurances that may have different deductible reset dates.

Copay

This is the amount you pay for a visit or medication. Different types of visits, like wellness visits or specialist visits, and different kinds of medications may have different copays.

Coinsurance

This is similar to a copay, but coinsurance is the percentage of a service fee that you’re responsible for paying. You may have a coinsurance rate of 20%, which means you would pay 20% of your medical bill, and your insurance would cover the other 80%. Different services can have different coinsurance costs.

Summary of benefits and coverage

This is an online or paper booklet of your health insurance benefits. Insurance companies are required to make a summary of benefits and coverage available to you. This guide tells you what is covered by your particular plan and includes things like copay amounts for different services. 

Explanation of benefits

This is a statement from your insurance company of costs and coverage for a specific service that you received, letting you know how much your insurance paid, and how much you paid or may be responsible for. An explanation of benefits, is just that, an explanation of costs; it is not a bill.

Prior authorization

Sometimes, your insurance requires a “prior authorization” before a service, like surgery or a prescription, is provided. If this is the case, your clinician will submit the prior authorization to the insurance company to get approval before your surgery is scheduled or your prescription is sent in. This is to ensure your insurance will cover whatever it is that you need.

In-network

In-network means that you get certain benefits and cost advantages when you use healthcare providers that are part of your insurance plan’s network. In-network care is usually more affordable and convenient compared to out-of-network care because your insurance plan has negotiated lower prices with these providers.

Out-of-network

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 providers, insurance plans typically cover a smaller portion of the expenses for out-of-network care, which means you may have to pay more. Your insurance plan may or may not have out-of-network coverage. 

HSA (Health Savings Account) or FSA (Flexible Spending Account)

Your insurance or employer may offer these types of savings accounts that you can use to pay for medical expenses. Money that is contributed to these accounts is pre-tax. You may be able to use your HSA or FSA to pay for appointments, medications, and other medical costs at FOLX, depending on your plan. (The FOLX membership fee is not reimbursable by these plans.)

We know that was a lot of information! You don’t have to memorize those terms but consider this glossary a reference as you make the most of your insurance coverage and navigate your care. 

How to Find Information About Your Insurance Plan

To find the details of your insurance plan and what is covered, your “Summary of Benefits” or “Explanation of Benefits” is the first place to start. This document should outline what your plan covers, details about deductibles, copays, and coinsurance, and what services are included in your plan. You can find it on your insurance company’s website or request a copy through their customer service.

Reaching out to your insurance company can also help you get your questions answered. Many insurance companies have either an online portal or app you can sign into, where you may be able to search to see if certain services are covered. You can also call the number on the back of your insurance card to speak to someone who will be able to give you specific information about your plan, or in some cases, there may be a live chat directly in their portal or app.

Unfortunately, your doctor or clinic won’t be able to answer specific questions about your coverage for you, so the best way to know what your insurance covers or how it works is to call the insurance company directly. Your doctor or clinic (and definitely us here at FOLX!) can help you by providing information like what services will be billed for (sometimes called “the codes”) or what medications they might be prescribing or lab tests they are ordering, to help you when you talk to your insurance company.

Advocating for Yourself with Your Insurance Company

You may find that you need to contact your insurance company to ask questions about your coverage, check in on a claim, or inquire about an unexpected bill. It can often be daunting to think about calling up your insurance company, but here are some tips that can hopefully help you feel less anxious about taking that step:

1. Know your plan.

You don’t have to be an expert in everything your plan covers, but you should at least become familiar with things like the name of your plan, your copays and deductibles, and whether or not you have out-of-network coverage. The more you know about your plan, the easier it will be to push back if something doesn’t seem right. If you’ve had a claim that is denied but you know it should be covered, it might be helpful to find the coverage in your explanation of benefits to be able to provide that information for the person you are speaking with.

2. Ask questions (and write them down beforehand!).

If you don’t know why something was denied or why you have received an unexpected bill, make sure to write down your questions to make sure you understand. Clarify anything that seems unclear and ask for written explanations if possible. 

3. Know your rights in your state.

If you’re gathering information or appealing a claim, especially about gender-affirming care, it is helpful to know what your rights are. Different states have different rules about insurance exclusions based on gender identity or sexual orientation. Check out this map to see the laws in your state.

4. Request a case manager.

If you have a more complicated situation, like dealing with multiple chronic conditions or an upcoming surgery, you can ask to be assigned a case manager. This person is someone within the insurance company who can help manage your treatment and ensure that your insurance plan covers everything.

5. Document your conversations.

Make sure you write down the names of any representatives you speak with, the date and time of the call, and the details of the conversation. This will not only help you remember, but if your claim is denied, this information will be helpful when filing an appeal.

6. File an appeal.

If your insurance has denied coverage for a service you’re entitled to, you can file an appeal. You can ask your insurance company to provide the steps necessary to file a claim appeal. Usually, this involves filling out some forms, either online or paper forms, and providing necessary documentation.

7. Reach out to FOLX Member Navigators.

If you are a member, you can reach out any time to get help from our Member Navigators. While they can’t submit an appeal for you, they can provide supporting documentation as needed. For example, they can resubmit the claim if the information was submitted incorrectly or incompletely, and if you need a letter from your clinician as part of an appeal process, they may be able to assist with that as well.

Common Questions About Using Insurance with FOLX

Does FOLX accept my insurance? 

We accept many nationwide and regional insurance plans for visits with our clinical team. If FOLX takes your insurance, then you’ll likely be able to pay your regular copay, coinsurance, or deductible for your visits. To view the list of insurance plans we currently accept, please see here.

If you don’t see your insurance, don’t worry—we are continuing to add new plans all the time. To make sure you are notified of any new insurance plans we accept, sign up for our newsletter here.

Do you accept my insurance in my state?

For some plans, FOLX is only able to accept them if you’re located in a certain state. This is due to billing regulations on the insurance company’s end. To check and see if your plan is accepted in your state, please see here and take a look at the “States Covered” column for each plan type. 

Do I need to set a designated primary care provider (PCP) for my insurance?

Some insurance plans require you to select a specific clinician as your PCP, who is responsible for managing your general medical care and writing any referrals for specialized care that you may need. To see if your insurance requires a designated PCP, check your summary of benefits or contact your insurance.

How do I set my FOLX clinician as my primary care provider (PCP) on my insurance plan?

If your insurance is in-network with FOLX, you can select your FOLX clinician as your designated PCP. To do so, we recommend calling your insurance company via the number on the back of your insurance card. From there, you can provide them with the name of the FOLX clinician that you’d like to be your PCP. If your insurance company requests additional information or has any trouble locating your FOLX provider in their directory, our Member Navigation team is here to help you! Please follow the steps below to get in touch:

  • Login to the Message Center
  • Click the Send a Message button
  • Select Billing & Insurance from the What can we help you with? dropdown.
  • Select I have a question about my insurance from the Select the option that best fits your request dropdown. 

I have a question about my claim. What do I do?

Our Member Navigation team is here to help you! Please follow the steps below to get in touch:

  • Login to the Message Center
  • Click the Send a Message button
  • Select Billing & Insurance from the What can we help you with? dropdown.
  • Select I have a question about my insurance from the Select the option that best fits your request dropdown. 

I have a question about my prior authorization. What do I do?

Our Care Team is here to help you! Please follow the steps below to get in touch:

  • Login to the Message Center
  • Click the Send a Message button
  • Select Billing & Insurance from the What can we help you with? dropdown.
  • Select I need help with a Prior Authorization from the Select the option that best fits your request dropdown. 

How do I know what my copay will be?

Your insurance company is always the best source of information for costs. On our end, we don’t have access to pricing information that is specific to your plan. If you call your insurance company and they need additional details about coding to determine cost, please reach out to us via the Message Center. From there, we’d be happy to provide whatever information we can!

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FOLX Health is the first digital healthcare company designed by and for the LGBTQIA+ community. Our services include primary care, gender-affirming hormone therapy including estrogen and testosterone (HRT), mental health care, sexual and reproductive health 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, nonbinary, or another identity, you can find LGBTQ-specialized health care that helps you meet your wellness goals. Get all the benefits of becoming a FOLX member and sign up today!