What Health Insurance Should I Get?
This is a common question we receive. Often, it is your employer who provides you with a choice between two insurance plans. It’s your responsibility to choose the best one for your situation each year. However, predicting out-of-pocket medical expenses can be challenging. We are here to help you navigate the decision-making process and review some essential information that you will need to know.
Considerations When Choosing Your Plan
When selecting a health insurance plan, think about these three key factors:
1. Cost: What are the premiums, deductibles, and other costs associated with the plan? How much did you pay for hospital stays or doctor visits last year? Is there a yearly cap on your out-of-pocket expenses for medical services?
2. Coverage: How well do the new options cover the services you need this year, including your medications?
3. Provider Network: Is your preferred doctor’s office or hospital in-network with the new plan? Do your doctors accept the insurance? Are the doctors you wish to see currently accepting new patients? Will you need to choose your hospital and healthcare providers from a specific network? Is a referral required for specialist visits?
How Does Health Insurance Work?
No one plans to get sick or injured, but unexpected medical needs can arise. Unfortunately, healthcare in the U.S. can be expensive. Health insurance helps cover some of these costs and provides benefits that many people may not realize.
Most importantly, health insurance protects you from unforeseen, high medical costs.
– You will pay less for covered in-network healthcare, even before you meet your deductible.
– You receive free preventive care, such as vaccines, screenings, and certain check-ups, even if you have not yet met your deductible.
The Basics of Health Insurance Terms
– Allowed Amount: The maximum amount a health plan will pay for a covered healthcare service. This is also referred to as the “negotiated rate” or “eligible expense.” If the provider charges more than the allowed amount, you’ll need to pay the difference. Even if the provider charges the allowed amount, you may still owe a percentage of the cost depending on your health plan (see coinsurance below).
– Coinsurance: The percentage of costs for a covered healthcare service that you are required to pay after meeting your deductible. For example, if your health plan’s allowed amount for a doctor’s visit is $100 and your coinsurance is 20%, after paying your deductible, you would pay 20% of $100, which is $20. Your health plan would cover the remaining amount. If you haven’t met your deductible, you would owe the full amount.
– Co-payment: A fixed amount you pay for a covered health service (e.g., $20 for a general physical exam). This is often referred to as a copay.
– CPT Code: Current Procedural Terminology (CPT) code is a five-digit code that providers use to bill for medical procedures. It is always included on the bill from the provider or in the explanation of benefits from your insurer.
– Deductible: This is the amount you are required to pay for medical services or products before your health plan starts paying a percentage (e.g., 70%) or 100% of an expense. Some plans may cover certain services, like an annual check-up, before you meet your deductible. Plans can also have separate deductibles for different types of care (e.g., a medical deductible and a drug deductible).
– Explanation of Benefits (EOB): This document provides an insurer’s explanation of the charges for a medical procedure and how those charges will be paid. It details what the provider charges, the allowed amount, the insurer’s payment, and your payment obligation.
– Formulary: A list of prescription drugs covered by your health plan, organized into groups or “tiers.” Typically, higher-tier medications will cost you more. A standard formulary includes:
– Tier 1: Generic medications
– Tier 2: Preferred brand-name medications
– Tier 3: Non-preferred brand-name medications
– Tier 4: Specialty medications, like biologics
– High Deductible Plans: These plans feature lower premiums and higher deductibles. They are often accompanied by a Health Savings Account (HSA), where contributions are tax-free and can be used for qualified medical expenses.
– Premium: This is the monthly cost you pay for your health coverage.
At Bodywise Physical Therapy, we have extensive experience dealing with insurance and can assist you with questions about your coverage or plan. Don’t hesitate to reach out to us for help!
