INSURANCE INFORMATION AND EDUCATION
In today’s complex health insurance marketplace, we strive to work with you and your insurance so that you can get the care that you need. Ultimately, it is the patient’s responsibility to understand the terms of his/her specific plan that they (or their employer) agreed to in their insurance contract.
Some or all of these terms may apply to you and some may not.
*If you have questions about your plan, the best thing to do is to call the phone number on the back of your insurance card and speak to a representative directly. This will get you the most accurate information. This is always best done before you receive any care so that you can get the insurance coverage you deserve!
DEFINITIONS IN HEALTH INSURANCE
1) Premium: This is the monthly “rent” or “subscription fee” that the patient has to pay the insurance company to carry health insurance.
Some plans will cover MORE healthcare costs and these plans usually have HIGHER monthly premiums.
Others, like high deductible plans, have lower monthly premiums but will NOT cover much – so the patient has to pay more out of pocket for care).
2) In-Network vs Out-of-Network: Insurance companies create networks of doctors and hospitals with whom they have negotiated more favorable contracts. Each specific plan has a specific network that is always changing each day. This information is not made available to the public.
BUT it is the responsibility of your insurance company to make sure that you have access to your network information.
To confirm that your doctor is in your network, call your insurance directly by calling the phone number on the back of your insurance card. This is best done BEFORE you receive any care so that you get the insurance coverage you deserve!
3) Copayment (or co-pay): A co-pay is a specific flat fee that is paid for each medical appointment. If the insurance company requires a co-pay, the patient will pay the set co-pay amount for each visit.
Example: If a patient’s visit costs $200, and the insurance has a co-payment of $30, then the patient will have to pay $30 at the visit. If they come back in a week, the patient will have to pay another $30 at this next visit.
4) Deductible: Some plans have a deductible, which is the amount of money the patient must pay each calendar year BEFORE their health insurance starts paying for covered expenses.
Example: If a patient’s insurance plan has a $2000 deductible and they have to have surgery that costs $5,000, then the patient is responsible for paying the first $2,000. After the $2,000 deductible is ‘met,’ the insurance company will then begin to contribute payment towards a percentage of the bill, which is called the coinsurance. Deductibles reset back to $0 each year.
5) Coinsurance: AFTER the patient meets their deductible for a calendar year, coinsurance is the cost-sharing part of the plan – the patient pays a certain percentage and the insurance company pays the rest.
Example: After meeting the $2000 deductible, a patient has another surgery that costs $5000. Her health plan has a 20% coinsurance so the insurance company pays 80% (or $4000) while the patient will pay the remaining 20% (or $1000).
6) Out-of-Pocket Limit: The out of pocket limit is the maximum amount that a patient will pay out of their own pocket for covered medical expenses in one specific calendar year.
Example: For a plan that has a $4,000 out-of-pocket limit, the patient will pay a $2,000 deductible and $2,000 in coinsurance. Once this limit has been met, ALL other medical expenses will be covered 100% by the insurance company if any additional medical problems arise within that same year.
INSURANCE PLAN TYPES
PPO (preferred provider organization): patients typically have flexibility to see doctors that are in- or out-of-network but this is dependent on their specific plan.
HMO (health maintenance organization): patients typically can only see providers that are in network AND they are required to have a primary care referral prior to seeing a specialist.
POS (point of service): patients can see a provider that are in or out of network but they need a referral from the primary care doctor.
EPO (exclusive provider organization): patients can only see providers that are in their specific restrictive network. No referrals are typically required.
If you have questions about your plan, the best thing to do is to call the phone number on the back of your insurance card and speak to a representative directly. This will get you the most accurate information.