Navigating your Health Insurance Plan

I work in a Podiatry office and deal with hundreds of insurance plans every week. I’ve learned a lot about how insurance works, and I’ve learned even more how little people understand or know their own coverage.

Here’s some information that will hopefully make your insurance plan a little easier to understand.

Words to know:

Copay – the payment you make at the beginning of each doctor’s visit. Instead of paying a different amount each time, you pay the set amount, and you are covered for a certain percentage after that. For me, if I pay my $20 copay, my doctor’s office visit is covered 100%. (This does not include and additional charges, such as an injection during the visit, or medical equipment. It only covers the consultation time with the doctor)

PCP – Primary care physician. General family doctor, non-specialist.

Deductible – the yearly amount that, if met, will open up your coverage benefits. Once you meet your annual deductible you do not have to meet it again until the next year. You do not have to meet your deductible. You do, though, if you want the coverage. In other words, it’s ok to not meet the deductible.  Even if you do meet it, many plans will still require you to pay a small percentage of the cost. Not everything will be applicable to your deductible, either. Just because you paid $275 for something, doesn’t necessarily mean that $275 will count towards your deductible. Sometimes only a percentage (or even nothing) is applicable. There are 2 kinds of deductibles that I’ve dealt with:

•          Individual deductible – the amount that you as an individual must meet
•          Family deductible – the amount that your family must meet. Often it is 2 or 3 occurrences (2 or 3 times) of the indiv. deductible.

Provider – another word for doctor or doctor’s office.

Referral – obviously a referral is a “referring to” by someone. In the case of insurance, your doctor would refer you to another doctor if necessary. If you are told that you need a referral (to a Podiatrist, for example) and don’t know how to get one, just tell them about whatever medical problem you are having (in this case, foot and ankle problems), and that you’d like an insurance referral to a specialist. They’ll know where to go from there. Within 10 days, you’ll receive, by mail, a copy of the referral, at which point you are able to make the appointment. Double check, though, that the specialist got the referral, too. They can’t make the appointment without it.

Specialist – a specialist is a doctor who [obviously]specializes in something (ie: they are not general practitioners or primary care associates). Your family doctor is not a specialist. At a specialist’s office, your copay may be higher than at a regular doctor.

HMO vs. PPO – If you have an HMO plan (Health Maintenance Organization), your insurance company creates a network of doctors that you can see. HMOs usually have a lower copay. However, these plans are not very flexible. If you want to see a doctor who is not in-network, you will have to pay to see them, or find another doctor. The only time they will cover an out-of-network provider is if it is a medical emergency, which must be proven. The trade-off for such strictness is that your out-of-pocket costs will be much lower. If you need to see a specialist, you must get a referral from your PCP.

PPO (Preferred Provider Organization) plans are more flexible, and may have higher copays, but allow you to see more doctors. Out-of-pockets may also be higher. There is also a network of doctors you are covered to see. If you see an out-of-network doctor, the PPO will cover some of the cost (unlike an HMO, which would cover none). You do not need a referral to see a specialist (you can just see them as needed).

POS (Point of Service) plans offer some PPO and some HMO benefits. You get to choose which benefits you want to use when you see a provider.

Coverage & Benefits – I’ll use some benefits from my own plan as an example. If you are “covered at 80% after you meet a $500 deductible,” and the cost of your procedure is $100, then you will have to pay the $100. You are only covered at 80% once your deductible is paid. So that $100 would most likely go towards your deductible (if applicable).

If your cost is $1000 you must pay $500 to meet the deductible, and once met, you will only be responsible for 20% of the remaining $500, so $100. Your total paid will be $600.

Some equipment and procedures may not be covered on your plan, or might have a lower coverage percent. Not everything has the same coverage. For example, in my plan, pediatrician visits are covered at 100% [which is of no use to me, since I have no children. Poop], but other things are covered at 80%. If I see an out-of-network physician, I am only covered at 50%.

Some questions you might have:

What is a good plan vs. a bad plan?

A good plan is one that has a low deductible and a high percent of coverage. In the end, you want to pay as little as possible for the most coverage possible. My plan covers most things – in-network – at 80% after an individual deductible of $250. That’s a pretty good plan. However, there are only 2 people in my family. The larger the family, the larger the deductible.

How much is the copay?

                Each plan differs, but for a typical doctor’s office visit, your copay may be between $0 and $100. I know, that’s pretty broad, but there are so many different companies and plans, that there is no standard copay amount. From personal experience of working in a doctor’s office, most copays are between $10 and $40. Some are lower or higher. My mother-in-law pays a $75 copay, which is really high. My copay is $20. You can see that there is a wide variety of copays. [Note: you don’t only pay copays at the doctor’s office. You may have an ER copay, which is generally high, like $80 or more. You may have a prescription copay, which could be $15 or more.

How do I get health insurance?

                You can get it directly from the insurance company, or you can get it from your employer. I’m covered as a dependant under my husband’s plan, which is paid for by his work. If your job does not provide health insurance, you can search different websites for plans that fit your family.

What are the best insurance companies?

                I’ve worked with a lot of different companies, and the ones that I think are the best are the ones that the most people have. These are, in my opinion, the top five (not including Medicare, since I think most of my readers aren’t quite eligible yet):

*Anthem Blue Cross

*Aetna

*United Health Care

Blue Shield

Blue Cross/Blue Sheild (weird, I know)

How do I know what counts towards my deductible?

                You don’t, unfortunately. I can’t help you with this one. You just have to call your insurance company, and they’ll tell you what will apply, or what won’t apply. 

I know it’s confusing. The easiest way to learn more is to call the insurance company directly. They’re usually really patient and helpful in explaining how it all works, and what you are covered for.