Understanding Your
Health Insurance
Understanding Health Insurance
Individual health insurance is a contract between you and
your insurance company, whereas employer group health
insurance is a contract between your employer and the
health insurance company. Health insurance helps pay the
costs of treatment for an illness or injury.
Shopping for Coverage
Depending on your situation, health insurance can be
obtained in several ways:
• Health Insurance Marketplace: An application may
be completed online at www.healthcare.gov or by calling
800-318-2596.
• Directly from a health insurance company: DIFS
provides a list of authorized health insurance companies
and Health Maintenance Organizations (HMO) and the
areas in which they offer coverage at
www.michigan.gov/DIFS.
• Through your or your spouse’s employer: Some
employers offer health coverage as an employee benefit.
• Through a college or university you attend:
Some higher learning institutions offer coverage to their
students.
• Through Medicare or Medicaid, for those who
qualify: For Medicare call 800-663-4227 or visit
www.medicare.gov. For Medicaid call Michigan Enrolls at
800-975-7630 or visit www.michigan.gov/mibridges.
For questions or help with purchasing health insurance, you
can seek the assistance of:
• A federally trained
navigator or certified
application counselor:
Trained individuals can
provide enrollment
assistance for Marketplace
plans. To find Marketplace assistance in your area, visit
localhelp.healthcare.gov.
• A licensed agent: To find licensed health insurance
agents in your area and to verify their licensure in
Michigan, use DIFS' Insurance Licensee Locator at
www.michigan.gov/DIFS.
Prior to purchasing health care coverage, you may want to
compare health insurance policies and find the policy that
best meets your needs. Consider the following:
• Identify your current health care needs by making a
list of:
o Your provider(s) and hospital(s)
o Your current health conditions and treatment
o Prescribed medication
• Compare the health insurance policy’s:
o Covered in-network and out-of-network benefits
o Treatment limits and exceptions
• Compare the cost of:
o Premiums
o Out-of-pocket expenses (i.e., deductible, co-
insurance, and co-pay)
For additional assistance comparing policies, see DIFS’
Health Insurance Shopping Tool located on the last page of
this guide.
Cost for Coverage
There is more to shopping for health insurance than just
finding the lowest premium. Considering your financial status
and family needs, the bottom line on your health insurance
may not be the monthly premium you pay. A policy with a
lower monthly premium may seem like a better deal, but a
lower monthly premium could mean you’ll have less
coverage – or that you’ll pay more out-of-pocket when you
need health care services.
Examples of out-of-pocket costs include:
• Deductible – How much you will pay before the
insurance helps pay for the cost of treatment.
Deductibles generally apply to most services. Check
your Summary of Benefits and Coverage for more
detail.
• Co-insurance or Co-payments – How much you
pay out-of-pocket for services after you pay the
deductible.
• Annual out-of-pocket maximum - How much in
total you’ll have to pay for treatment in a plan year.
What’s Covered
Health insurance helps pay for provider visits, hospital
services and medications. But remember, insurance isn’t just
for when you get sick – it can also help you stay healthy.
Most plans cover preventive services like immunizations,
annual visits, screenings and more for free.
For more information on what your plan covers, review the
“Summary of Benefits and Coverage.” If you don’t have one,
ask your insurance company for a copy. The Summary of
Benefits and Coverage explains the plan’s key features like:
• Covered health care services
• Your share
of the costs
for a
covered
service
• Health care
services the
plan does
not cover
Things to Remember
1. There are many kinds of private health insurance
policies. Different kinds of policies can offer very
different kinds of benefits. Some policies may also have
a certain group, also known as a network, of health care
providers you can use when you need care.
2. Health insurance companies contract with networks of
hospitals, pharmacies, and health care providers to take
care of people in their plans. Depending on the type of
policy you buy, your plan may only pay for your care
when you get it from a provider in the plan’s network, or
you may have to pay a bigger share of the bill.
3. You may have to pay co-insurance or a co-payment as
your share of the cost when you get medical services,
like a provider’s visit, hospital outpatient visit, or a
prescription.
4. You may have to pay a deductible each plan year before
your insurance starts to pay for care you receive. See
the previous page for an example.
5. You may see limited benefit products that appear to
provide the same coverage as comprehensive health
insurance. Some examples are short-term limited
duration policies, policies that only cover certain
diseases, policies that only cover you if you’re hurt in an
accident or plans that offer you discounts on health
services. Don’t mistake limited benefit products for
comprehensive health insurance.
Disputes with Your Health Insurance Company
If your health insurance company denies a claim or ends
your coverage, you have the right to appeal the decision. An
attorney is not required to resolve most disputes. Start with
contacting the health insurance company in writing and
request a reconsideration of its decision.
If your dispute involves a decision your health insurer made
regarding your health care claim, also known as an adverse
determination, there are two levels of appeal – an internal
appeal with your health insurer and an external review with
DIFS.
The external review process should only be initiated if: 1) the
covered person has exhausted the health carrier’s internal
grievance process, or 2) the health carrier fails to provide a
determination within the timeframe dictated by law.
If you’ve exhausted your health carrier’s internal grievance
process and you do not agree with their final adverse
determination, you have 127 days to file an external review
with DIFS under the Patient’s Right to Independent Review
Act (PRIRA). For additional information related to DIFS’
external review process and to access the Health Care
Appeals-Request for External Review form, visit
www.michigan.gov/DIFS or contact DIFS at 877-999-6442.
Upon receipt, DIFS will examine your external review request
to determine if it meets the requirements under PRIRA.
In any case, you always have the right to file a written
complaint with DIFS if you are unable to reach a satisfactory
resolution. DIFS will send the health insurance company a
copy of the complaint and ask them to explain their position.
Health insurance companies are required by law to respond
to DIFS. We will review the facts to ensure the health
insurance company has complied with your contract
language and all rules and regulations.
Complaints Can Be Submitted in the Following
Ways:
• Online: www.michigan.gov/DIFScomplaints
• Email: DIFScomplaints@michigan.gov
• Fax: 517-284-8837
• Mail: DIFS, PO Box 30220, Lansing, MI 48909
Contact DIFS toll-free at 877-999-6442 for additional
information or to request a complaint form be sent to you via
mail, email or fax.
Health Insurance
Shopping Tool
Things to discuss with your insurance company, agent, or
assister:
Name of company/plan
Monthly premium
Is your doctor
in-network?
Is your hospital
in-network?
Are the prescriptions
you’re taking covered?
Deductible
Co-insurance
percentage
Co-pay:
Office visit
Urgent care
Emergency room
Prescription co-pay:
Generics
Brand name
Specialty
Mail order
NOTES:
CONTACT INFORMATION
Michigan Department of Insurance and
Financial Services Telephone: 877-999-6442
DIFS-HICAP@michigan.gov
www.michigan.gov/HICAP
FIS-Pub 6200 Rev. 05/19