Increasingly, patients are coming in with more and more questions about their health insurance coverage. For the most part, when someone signs up with a plan, they get a package of information that doesn’t adequately answer their questions. Either there is too much information to glean out what is important or it is just not explained well. Patients often get upset when asked to pay for a deductible that they didn’t know they had. But, with the changes in the recent healthcare ecosystem, it is extremely important for patients to understand their benefits.
What do patients need to know about healthcare insurance?
1. What is a deductible? Under the ACA. many patients are finding they are now responsible for higher deductibles under the plan they signed up for under the insurance exchange program. A deductible is a certain dollar amount that a patient has to pay out-of-pocket before the insurance coverage kicks in. I have seen amounts ranging from $500-$5000. This is an annual deductible. For example, every year, you are responsible for paying your deductible for any medical services until you have paid the full amount of your deductible. After the deductible is met, the insurance will then start making payments for your medical services.
2. Why do I have to pay a copay every time I see the doctor? This is something you agreed to when you signed up for your insurance. It is law that a doctor must collect the copay whenever you come. If a doctor does not collect the copay, it is a violation of anti-kickback laws and is seen as the doctor is giving you a kickback to be their patient. If you are not happy with your copay, talk to insurance company to see if there is a better plan to match your needs.
3. My plan is a HMO. What does mean? This is a health maintenance organization. Every patient enrolled in a HMO needs to choose a PCP (primary care physician). That physician is responsible for overseeing all your care. You need referrals to go to any specialists. If you go to a specialist without a referral, the insurance will not pay for that service. Also, PCP’s are not allowed to back date referrals. Check to see if you need a referral before you see the specialist.
4. What is a PPO? This is a preferred provider organization. With this plan, you do not need to select a PCP and do not need referrals to see specialists, for the most part. However, you still need to stay in the insurance plan’s network otherwise your coverage may not pay depending on whether you have out-of-network benefits. Most often you will not.
5. What is the difference between Medicaid and medicare? Medicare is a federal program and to be eligible, you must be 65 years of age or older or be deemed disabled and unable to work. Medicaid is a state-run program for those under a certain minimum wage. Paperwork needs to be filled out to determine your eligibility
6. My doctor’s office told me to check the EOB. What is an EOB? This is the explanation of benefits that the insurance company sends you every time a claim is submitted on your behalf. It shows what charges were submitted for every procedure you had done, what is allowed to be collected by the doctor under their contracts with the insurance plans, and the amount of money that is written off. It will also show you any money you are responsible for paying, including deductibles and co-insurances.
These are the most common questions I see asked in my practice. It is imperative that patients understand what they need to pay and why. While the doctor’s staff can sometimes help you answer your questions, the insurance company is often the only one who truly knows the answers.
