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What terms should you know when choosing your health insurance plan?
Premium - A monthly amount you pay the health insurance company.
Deductible - A yearly fixed amount that you pay towards your medical costs before your insurance begins paying towards these costs.
Coinsurance - The percentage of your medical costs you share with your insurance company after you’ve met your deductible amount. There are plans that cover at 100% once you meet your deductible; however, if it does not you will have to pay this coinsurance amount. “For example, if you have a $100 doctor’s bill and your plan covers 80 percent of it, your coinsurance amount due to the doctor’s office is 20 percent, or $20.”
Copayment - A flat fee you pay every time you see a physician or fill a prescription. This amount does not go towards your deductible.
Out-Of-Pocket Maximum - The amount you, as the patient, have to pay for covered medical services in a year. Example: You have a $32,000 surgery. Your deductible is $1,700, coinsurance is 20%, and out-of-pocket maximum is $3,600. You would pay the $1,700 deductible amount. Your remaining cost is $30,300. Your 20% coinsurance of this amount comes to $6,060. The total amount of these costs for the deductible and coinsurance is $7,760; however, your out-of-pocket maximum is $3,600. Your insurance company will pay all costs above $3,600 for this surgery and any covered care you get for the rest of the year.
What are the different types of health insurance plans?
Health Maintenance Organization (HMO) - These plans have lower premiums and deductibles, but have restrictions on the providers you can visit. You will need to select a primary care physician (PCP), as referrals are required for specialists’ visits.
Preferred Provider Organization (PPO) - These are the most popular plans. You do not need to select a PCP nor do you need a referral for specialists visits. These plans do have higher premiums and deductibles compared to HMO plans; however, there is also a larger network of providers you can see compared to HMO plans and likely out-of-network services.
Point-Of-Service (POS) - For this plan you are likely required to select a PCP and they will help you coordinate your care. No referral required for specialists visits.
Exclusive Provider Organization (EPO) - This plan is similar to HMO plans, but you do not need to choose a PCP nor is a referral required for specialists.
What are your covered costs?
Insurance policies specifically list the types of costs that are covered or are not covered under your plan. For example, some plans do not cover pre-existing conditions or they may not include maternity benefits. Other plans may not pay when you see an out-of-network doctor. It is up to you to know what your health insurance plan covers.
How does a high-deductible health plan affect your care?
With a higher minimum deductible, you will have lower premiums. Meaning you may pay less each month, but you will be responsible for paying the cost of your healthcare up to a particular amount (your set deductible) before you insurance begins paying for it.
These plans do provide exceptions for preventive care expenses, such as, screenings, check-ups, etc.
You can combine this health plan with a Health Savings Account (HSA) or Health Reimbursement Arrangement (HRA) to help with medical costs, but this plan may not be combined with any other health plan.
What does Medicare cover?
It is important to enroll in Medicare as soon as you become eligible. If you do not, you may be hit with a late enrollment penalty fee.
Medicare coverage consists of 4 parts:
Part A- Hospital Insurance
1.There is no premium.
Part B- Medical Insurance
1.There is a set monthly premium.
Part C- This gives you the choice to receive the benefits of Part A, B, or D through a private health plan.
Part D- Prescription Drug Coverage
What are Medicare Advantage plans?
These are Medicare health plans that cover all services that original Medicare covers including, Part A and Part B benefits, except for hospice care. These plans replace traditional Medicare for the time period you are enrolled in the advantage plan. “Medicare Advantage Plans have a yearly limit on your out-of-pocket costs for medical services. Once you reach this limit, you’ll pay nothing for covered services. This limit may be different between Medicare Advantage Plans and can change each year. Please take this into consideration when choosing your plan.
How does Medicaid work?
This provides health care for eligible people with limited income. Eligibility includes ages, pregnancy, blind, disabled and limited income and resources.
What’s the difference between a screening and a diagnostic colonoscopy?
A screening is a test provided to a patient in the absence of signs or symptoms. A screening colonoscopy is a service performed on an asymptomatic person for the purpose of testing for the presence of colorectal cancer or colorectal polyps. Whether a polyp or cancer is ultimately found does not change the screening intent of that procedure.
As part of the Affordable Care Act (ACA), Medicare and most third-party payers are required to cover services without a co-pay or deductible:
- Patient is 50 years of age or older
- Patient does not have any gastrointestinal sign, symptom(s), and/or relevant diagnosis
- Patient does not have any personal history of colon cancer, polyps, and/or gastrointestinal disease
- Patient may have a family history of gastrointestinal sign, symptom(s), and/or relevant diagnosis
A diagnostic colonoscopy is a test performed as a result of an abnormal finding, sign or symptom (such as abdominal pain, bleeding, diarrhea, etc.). Medicare and most payers do not waive the co-pay and deductible when the intent of the visit is to perform a diagnostic colonoscopy.
What is a surveillance colonoscopy?
A surveillance colonoscopy can be performed at varying ages and intervals based on the patient’s personal history of colon cancer, polyps, and/or gastrointestinal disease. Patients with a history of colon polyp(s) are not recommended for a screening colonoscopy, but for a surveillance colonoscopy.
Surveillance colonoscopies are most often covered under diagnostic benefits, even if the patient is asymptomatic. Guidelines are inconsistent across payers; check with your individual payers for their guidelines.
Disclaimer: Please review all of these items with your insurance agent prior to choosing a health insurance plan.