A Guide to Health Insurance

Navigating the System

Empower yourself as a patient, and learn how to get the most out of your benefits. Each plan is different, so this section of our guide will help you understand what it is that you should look for when you receive your insurance information.  This section will help you navigate the health care system when you need care.

  • Navigating the System
    • Getting care, what's covered
If you are having a health emergency, you do not need to get permission to access emergency care. Health plans do not require permission or authorization for a sick or wellness visit with a primary care provider. Prior authorization from your insurance company is different from receiving a referral from a primary care doctor. Some services require prior authorization in addition to a referral. Prior authorization gives the clinical staff at an insurance company the chance to review treatment...
  • Navigating the System
    • Getting care, what's covered
Most health plans cover some chiropractic care for acute or short-term conditions. New Hampshire statute requires health plans that cover chiropractic care cover a minimum of 12 visits. You may be required to pay a co-pay at the time of your visit, so be sure to check your Summary of Benefits and Coverage Document. However, many insurance plans do NOT cover chiropractic care for maintenance and wellness treatments. If you are being treated for a chronic, long-term condition, refer to you...
  • Navigating the System
    • Getting care, what's covered
Yes. In fact, most health plans must cover a certain set of preventive services at no cost to you, when delivered by an in-network provider. Screenings and Counseling Screening for diabetes, cholesterol, obesity, various cancers, including prostate, HIV, and sexually transmitted infections (STIs) Counseling for drug and tobacco use, healthy eating, and other common health concerns   Routine Immunizations Recommended routine immunizations for adults and children such as influenza, meningitis...
  • Navigating the System
    • Provider networks and referrals
No, you are responsible to check if a provider is in your network. Every insurance company has different benefit plans and network requirements. It is also common for healthcare providers to move in and out of different health plan networks, making it hard for your doctor to know what providers are included your network. However, your provider's office will often help you by contacting the insurance company to make sure the referral is in your network. Ask your provider for assistance if you...
  • Navigating the System
    • Getting care, what's covered
There are many resources available to help you find behavioral health care or substance use disorder services. If you or someone you know is in crisis and need help immediately Call 911 in case of an emergency or life threatening situation. The New Hampshire Statewide Addiction Crisis Line is available 24 hours a day at 1-844-711-HELP (4357). The National Suicide Prevention Lifeline is available 24 hours a day at 1-800-273-TALK (8255). A trained counselor will help you with any problems you are...
  • Navigating the System
    • Making the most out of your coverage
Spending a little time to prepare before you go to the doctor can help you get what you need from the visit. Think about why you are going to see the doctor  
  • Navigating the System
    • Provider networks and referrals
Out-of-network services typically cost you more Your insurance plan has contracts with doctors, other health professionals, pharmacies, and facilities to provide needed care and services, known as benefits, for plan members.  "In-network" is the term used to describe these contracted providers. The plan pays the in-network providers an agreed rate for care and services, usually at a discount. This reduced rate means that services typically are provided at a lower cost to you.  
  • Navigating the System
    • If you're uninsured
If you don't have health insurance, paying for care can seem overwhelming. If you need care, it is important that you get medical care before you get worse. There are many resources available to help you.  Start now to get the coverage and care you need.
  • Navigating the System
    • Provider networks and referrals
When your doctor needs to refer you to a specialist for care, first talk with the doctor's office staff to see if there is an in-network specialist contracted with your insurance plan. Remember that the doctor's office may not know what providers are included in your insurance plan network.  If in doubt, call your plan customer service directly. If you find that your insurance network does not include the needed specialty provider, coverage for services depends on your insurance plan benefits...
  • Navigating the System
    • Urgent or Emergency Care
Yes. If you need emergency dental care and go to the Emergency Room (ER), the ER will treat you and then bill your health insurance. The ER is not likely to be able to treat a dental problem unless it is a health emergency. They may use temporary measures to relieve pain until you are able to see a dentist. Your coverage will depend on your health plan. You can either check your plan documents or website or call your insurance customer service to verify coverage. Planning ahead The best plan is...
  • Navigating the System
    • Urgent or Emergency Care
If it's an emergency, call 911 or go to the emergency room right away! Emergency rooms are open 24 hours a day for injuries or illnesses that pose a threat to someone's life or long-term health. If you have a medical emergency, go to the closest hospital -- you'll be treated whether you have health insurance or not. If you go to an emergency room, you may not have a choice about what doctor provides care. Even if you have health insurance and go to an in-network emergency room, you may receive...
  • Navigating the System
    • Provider networks and referrals
A referral is like getting a prescription from your regular doctor to go see a specialist. Referrals have expiration dates. Some have a limit on the number of visits. So, if you need to see the specialist after the end date on the referral or for more visits, you will need to get another referral. You could pay a lot more If your plan requires a referral but you don't get one, you could pay a lot more. For example, your plan may charge you a penalty, cover the visit at a lower level, or not...
  • Navigating the System
    • Provider networks and referrals
Often, when doctors are out sick, their office staff calls to notify patients and reschedule appointments. Sometimes, instead of rescheduling appointments, a doctor may refer patients to another doctor. If you plan to see a doctor that is covering for your primary care provider, it is your responsibility to confirm that the covering doctor is in-network before you receive care. Learn more about provider networks.
  • Navigating the System
    • Getting care, what's covered
Alternative health care services are health treatments that are not typically provided in a traditional Western medicine practice. There are a wide range in practices, but typically these services focus on creating health through balance between mind, body, spirit, and environment. Research can help you understand the pros and cons of alternative care options. There are different categories of alternative health services.  "Complementary" treatments are used with standard medical practices; "...
  • Navigating the System
    • Provider networks and referrals
  Provider networks are made up of doctors, other healthcare providers , pharmacies, and facilities who contract with insurance companies to become an "in-network" provider. If you go to a provider who is in your insurance company's network, you will typically pay less than if you go to an "out-of-network" provider who doesn't have a contract with your insurance company. Insurance companies have different networks of healthcare providers for different health plans, so it's important to check...
  • Navigating the System
    • Urgent or Emergency Care
An urgent care center is a walk-in clinic that focuses on caring for patients who need care right away but are not having a life-threatening emergency. If it's an emergency, call 911 or go to the emergency room right away! Generally, you don't need a referral, just be sure to go to an in-network urgent care center. If your problem is less serious, you may be better off going to urgent care center. You may get care more quickly and less expensively than you would in the emergency room. Why go to...
  • Navigating the System
    • Getting care, what's covered
Keep in mind, health plans only cover what they consider "medically necessary." For example, plastic surgery would not be covered just because you want to improve the way you look. But, it would likely be covered to fix a problem (even if afterwards you like your nose better).                                      Major medical type commercial health insurance is linked to covering health care services, not disease conditions.  When the service is medically necessary and covered under the...
  • Navigating the System
    • Getting care, what's covered
H ealth insurance is not always easy to understand. Take some time to find out what your insurance will pay for and learn how to use your coverage. Be on time with your premium payments If you bought health insurance yourself, you should get the first bill from your insurance company within 10 days of signing up. You could lose your coverage if you don't pay your premium on time every month. If you don't receive a bill, call customer service and ask about it. If you have health insurance...
  • Navigating the System
    • Provider networks and referrals
What are narrow network plans? A narrow network plan refers to a health insurance plan with a smaller than usual, or "narrow," provider network. In a narrow network plan, health insurance companies try to lower costs by working with a smaller number of providers and fewer in-network facilities. Narrow network plans are offered by employers, through the Health Insurance Marketplace (www.HealthCare.gov), and in Medicare and Medicaid plans. Why might you choose a narrow network?