FAQs About Finding and Using Care After Insurance Approval

Insurance plans will offer a greater benefit if services are rendered by an in-network provider, and some won't cover out-of-network providers at all. Here are some tips on finding a provider in a specific insurance carrier's network.

Check The Carrier's Find A Doctor Tool from Your Zenefits Account

Also commonly called the Find A Provider tool, the insurance carrier has a directory on their website that can be used to find an in-network provider based on the network and location. This is a good first step to finding someone in a certain area that takes a specific insurance plan. Zenefits provides a direct link to your carrier's Find a Doctor tool on your Overiew page.

Call The Carrier

If the site's Find A Doctor tool isn't getting the job done, call the insurance carrier to confirm a provider's status. You can find your carrier's Member Services number on your Overview page.

Call The Provider Directly

Calling the provider's office directly is often the most surefire way to confirm participation in a network or acceptance of the insurance plan. When in doubt, call the provider directly before your service to confirm their status.

Ultimately, the best source for finding how to get a pharmacy expense reimbursed will be your carrier. However, we have compiled some helpful tips for you below.

Reimbursements for pharmacy expenses within 30 days

  1. Claims filed within 30 days of the prescription being filled can be directly reimbursed through the pharmacy where the prescription was filled/purchased.

    • The plan member will need to present their carrier ID card and a receipt showing the amount they originally paid.

  2. The pharmacy can then run the claim for the prescription through the carrier's pharmacy claim system and provide a reimbursement for any costs that were previously paid out of pocket.

    • Reimbursements do not include copay amounts.

    • Some pharmacies will allow direct reimbursements for up to 90 days, but 30 is a good rule of thumb.

Reimbursements for pharmacy expenses after 30 days

  • If the 30-day direct reimbursement period has passed or the pharmacy will not honor the receipt, the plan member would need to submit a claim form through their carrier's pharmacy vendor.

  • These claim forms can be obtained on the carrier's website, which you can find the Overview page in the Medical, Dental, or Vision Insuranc card.

    • Reimbursement through the carrier typically takes 30 days.

    • The carrier will issue payment directly to the member.

All US group health insurance plans cover emergencies abroad during international travel. Doctor's visits, standard services, etc. will not be covered unless explicitly stated in the plan or added on as a policy rider. Going to the ER for a sinus infection or a cold will not be covered; it's the medical nature of the service that denotes whether something is an emergency, not where the service is administered.

Refer to the plan's Summary of Benefits and Coverage for more information. Carriers will generally only allow an employee to stay on the group insurance coverage for a set amount of time while they are overseas. After that time period expires, they will mark the employee as ineligible for group coverage.

Travel insurance is coverage intended to protect against items such as medical costs, lost luggage, flight cancelations, or other expenses occurred during domestic or international travel.

Zenefits does not administer or provide advice on travel insurance. Travel insurance is not linked to group insurance policies.

Employees who are interested in signing up for travel insurance will need to speak directly with their insurance carrier.

When an employee has two different insurance plans at the same time, they have dual coverage. One plan will be designated as the primary plan and will pay first, the other will be designated as the secondary plan and will pay second.

  • Certain carriers have a policy where any plan without a Coordination of Benefits provision always pays first.
  • If the person receiving benefits is the participant under the contract (the policyholder), that health plan will be primary. The spouse’s health plan will become secondary.
  • If a dependent child is covered under two or more plans, the child's primary plan will be the one that belongs to the member whose birthday occurs earlier in the calendar year. This is known as the birthday rule. However, two exceptions to this rule exist:
    • If both members have the same birthday, the policy that has been in effect longer will be primary.
    • The birthday rule is overruled when a court order or custody rule applies.

Primary/secondary plan status is established by the carrier and cannot be determined by the employee.

This is useful in the event that the insured receives services, they can submit both lines of coverage and there's the possibility that one carrier will cover what the other carrier does not.

For more information on coordination of benefits with Medicare, see medicare.gov.

As of May 2015, federal regulations require that insurance providers cover all of the 18 contraceptive methods approved by the FDA for women at no additional charge. Any products or options recommended by a provider must be provided at no cost as well.

The following categories are required to have at least one option fully covered:

Contraceptive Method Options
Surgical sterilization N/A
Implant sterilization N/A
Implantable Rod Multiple
IUD – Copper Multiple
IUD – Progestin Multiple
Injection Multiple
Oral contraceptives – combined Multiple
Oral Contraceptives – progestin only Multiple
Oral Contraceptives – extended/continuous use Multiple
Patch Multiple
Vaginal Ring NuvaRing only
Diaphragm with Spermicide Milex Omniflex only
Sponge with Spermicide Today Sponge only
Cervical Cap with Spermicide FemCap only
Female Condom Multiple
Spermicide alone Multiple
Emergency Contraception-Progestin Multiple
Emergency Contraception- Ulipristal Acetate ella only

Does this apply to men as well?

Items that are considered preventive such as male condoms may be fully covered by a carrier, but items such as vasectomies are not considered preventive and may be subject to copay requirements. If you're curious if your plan covers any of the above, contact your insurance carrier directly to receive clarification.

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