HEALTH INSURANCE MATTERS

When you visit a healthcare professional in your insurance group, you typically have to provide personal information, your medical history, and you may also have to make a payment before you leave the office. This money is known as a copayment. Your health insurance policy determines this dollar amount, which you are required to pay for certain healthcare services, like physician office visits. Typically, copayments do not count toward your out-of-pocket maximums. Check with your HR manager or department to see if your healthcare plan requires copayments.

Your deductible is the fixed dollar amount that you must pay before your health insurance plan pays its portion of your medical bills. For example, if you have a health insurance plan with an annual deductible of $200 and an 80% coverage level, you must pay $200 worth of the medical bill before your health plan will pay its 80% share of the costs. After you have paid $200 in medical bills, the insurance company should cover the rest of your eligible medical expenses at 80% for the remainder of the year. Deductible amounts vary from plan to plan. Generally, higher deductible plans cost less than plans with lower deductibles. So which is better, an insurance plan with a high deductible and low premiums or a plan with a low deductible but high premiums? The answer depends on several factors like – your overall health, how often you get medical care and your finances. Figuring out the proper deductible is a personal choice that depends heavily on your medical and financial needs.

It looks like a bill, feels like a bill, but an Explanation of Benefits (EOB) is not a bill. If you have a health plan, it’s the statement you get from your insurance company after you receive services from a healthcare provider. The EOB lists several things including the services you received, the amount of cost your plan covers and the total amount billed to you. So, though it’s not a bill, it often tells you what you’ll end up paying. It also explains why a claim was or was not paid. Each time you receive an EOB, you should review it closely to see if there are any mistakes. Some companies recommend you keep all of your EOBs for at least two years.

An HDHP is a type of health insurance plan. It is characterized by higher annual deductibles and lower premiums than traditional health plans like PPOs. HDHPs do not cover healthcare-related expenses until minimum deductible amounts are met. However, once met, you’re often covered 100% for in-network providers. Please note that you may also be able to choose out-of-network providers but, like other plans, using in-network providers will save you money. A qualified HDHP is often combined with a tax-advantaged program, such as a Health Savings Account or a Health Reimbursement Arrangement. In the case of an HSA., you can use the money in your account to pay for qualifying medical expenses or qualifying care to meet your plan deductible. Both employees and employers may be able to contribute to an HSA account. To learn whether or not an HDHP is an option for you, check with a representative of your HR and/or Benefits Department.

You want to stay healthy and keep your healthcare expenses low. Who doesn’t? An important part of wellness is knowing how to utilize the services offered by your Health Maintenance Organization, (HMO). With an HMO, you pay a set fee, usually monthly or yearly. Because costs are fixed to members in advance, preventive care is key in an HMO arrangement. It’s to an HMO’s advantage to keep you healthy and try to reduce unnecessary or expensive services. While covered benefits vary among the plans, generally healthcare providers encourage you to take advantage of well-person visits and check-ups. As a covered member, typically you will have to choose a primary care doctor or P-C-P from a list of approved physicians. This doctor coordinates your care, which means that in most cases you must contact him or her to be referred to a specialist. In many plans, specialist visits are only paid for if you are referred by your primary care doctor. Some plans also allow women to chose an OB/GYN, whom they can see without a referral. Some chronically ill patients may also be allowed to select a specialist in the field of their illness as a PCP.

In some HMOs, you will pay nothing when you visit doctors. With other HMOs, there may be a copayment for some services. Depending on the type of plan you have, you may be able to go out of your network and visit another doctor by providing a copayment or you may have to pay the entire cost for the out-of-network services. Check with your HR manager or HR department to learn what options are available in your plan.

A Health Savings Account, or HSA, allows you to pay for qualified medical expenses with tax-free money. To qualify for an HSA, you must have a high deductible health plan, otherwise known as an HDHP. In general, you can use the money in your HSA to pay for deductibles, copayments, and other expenses not covered by your health plan, like dental or vision expenses. It can also be used to cover transportation and lodging when related to health care. If you don’t use all the money in your account by the end of the year, don’t worry. The money rolls over from year to year. An HSA is also portable, so you can take it with you if you change employers.

A premium is the money a person pays, typically each month, to maintain his or her insurance policy. Insurers may decide how much to charge you in premiums based on their prediction of potential costs of providing coverage. For example, when you apply for coverage, an insurer may ask about your current health status, prior medical history, age, gender and other characteristics. This process is known as medical underwriting and it is not allowed in some states.
Keep in mind; insurance plans that offer the most extensive coverage are often associated with higher premium costs. For example, a high deductible health plan (HDHP) is usually less expensive than traditional medical coverage. Talk with your benefits or HR representative to learn if your company offers insurance products with lower premium options.

In many healthcare plans, such as a PPO or an HMO, an in-network provider is a doctor, hospital or other healthcare professional that has an agreement with your insurance company to provide services to plan members for a set rate.

This in-network provider, sometimes called a preferred care provider, specifically accepts your insurance carrier and plan type. That usually means your insurance company will pay a larger percentage of your healthcare charges.

An out-of-network provider is any provider that does not have a contract with your healthcare plan. Generally, your insurance company will pay less money or not pay anything at all for services you receive from out-of-network providers.

To save money, it’s important to understand who is an in-network provider in your healthcare plan. To learn more, contact your health benefits administrator.

Open enrollment, also known as annual enrollment, is a period of time usually, but not always, occurring once per year, when employees of U.S. companies and organizations may make additions, changes or deletions to their elected fringe benefit options. In most cases, employees can only make changes in benefits elections during open enrollment or when they have experienced a specific qualifying event like the birth of a child or marriage. During this time period, an employer will typically communicate to all eligible employees what options they have for their benefit program. Open enrollment is your opportunity to review your insurance and spending accounts benefits coverage and make choices for the upcoming calendar year. You should actively enroll during open enrollment to ensure your benefits meet your needs.

A PPO is a type of healthcare coverage an employer may offer its employees. In a PPO, a group of doctors, hospitals and other healthcare professionals have contracted with an insurance company or a third-party administrator to provide their services to PPO customers at a discounted rate. Healthcare professionals within the PPO plan are sometimes called “in-network providers.” This means if you receive services from an in-network provider, your insurance company will pay a larger percentage of your healthcare charges. Depending on the type of PPO plan you have, your insurance company may or may not pay a percentage of the cost of services if you visit an out-of-network provider. Either way, out-of-network visits may cost you more out-of-pocket money. That’s why if you are a member of a PPO plan, it is usually beneficial from a cost perspective to find care from a PPO provider when possible. It is also important to note, if you need a specialist, some plans may require you to see a primary care physician who must refer you to a specialist in order for you to receive your highest level of benefits. Other plans may let you visit any doctor you’d like. Typically, if you have a PPO, you pay a premium to maintain your coverage. Check with your HR manager or department to learn if your company offers a PPO plan and if so, the details of that plan.