Understanding medical insurance coverage and plans can be difficult and tricky. Each year insurance plans are updated and previously covered procedures or medications may no longer be covered like the previous year. Just because you have medical insurance coverage does not mean you don’t have any other costs to pay.
The best way to understand the complexities of your medical insurance plan is to contact your insurance company. However, let’s take a look at the terms you will need to know to be an educated consumer and advocate for your care.
How Doctors Get Paid
Your doctor submits a claim to bill your insurance company. However, your doctor generally does not get paid the full cost of their services. A doctor agrees to join an insurance network of healthcare providers (or be in-network). Being in-network means that your doctor and insurance company have agreed on a set price for healthcare services for you, which is usually a discounted rate of the doctor’s full fee (called the allowed amount). If you choose an out-of-network doctor, then you will be responsible for part or the full bill.
Differences Between HMO and PPO
Two of the most popular health insurance plans are health maintenance organizations (HMOs) and preferred provider organizations (PPOs). Each type of plan has its own advantages and disadvantages.
The premium costs for HMO may be lower than PPO plans. HMO plans require a referral from your primary care doctor to see a specialist and you have to see an in-network specialist. PPO plans do not require a referral from your primary care doctor for a specialist and you can see an out-of-network specialist but may have to pay more for out-of-network care. Deductibles and copays for HMO plans may be minimal. PPO plans may have higher deductibles and copay costs. You do not have to file claims for HMO plans but with PPO plans you may have to file claims for out-of-network care.
Premium
The amount that is paid to your health insurance plan monthly, quarterly or yearly. This may be paid by you or your employer.
Deductible
The amount of money you must pay out of pocket each year before your health insurance starts paying for healthcare services. For example, if your deductible is $1000 then your plan won’t pay anything until you meet your $1000 deductible for the year. Usually, the lower the premium cost, the higher the deductible amount. Deductibles are a set amount (such as $500 or $1000).
Coinsurance
A percentage (such as 20%) of the allowed amount for covered healthcare services that you must pay after your deductible amount has been paid. You are responsible for your deductible and coinsurance. For example, if your office visit is $100 and you meet your deductible, then your payment of 20% coinsurance of $100 is $20.
Copay
A standard fixed amount (such as $50) that you pay at the time of service every time regardless of your deductible amount. You will continue to pay your copay for each doctor visit even after you have met your deductible and coinsurance.
Out of Pocket Maximum
The maximum amount you have to pay per year before your insurance starts paying 100% for all covered healthcare services. You are responsible for your copay + deductible + coinsurance = your out of pocket maximum.
In-network
Doctors or medical facilities that have a contract with your insurance plan to provide covered health care services.
Out-of-network
Doctors or medical facilities not contracted with your insurance plan. Out-of-network services may have higher costs because your insurance plan has negotiated lower costs for in-network care.
Referral
A written order from your primary care doctor for you to see a specialist or get certain health care services. HMO plans require a referral. If you don’t get a referral from your primary care doctor, then your insurance plan may not pay your bill and you will be responsible for the full amount.
Prior Authorization
Approval from your health insurance plan agreeing to cover medications or certain health care services.
No Insurance. No Problem.
If you do not have insurance, you can still get affordable care. Your doctor may offer discounted rates for self-pay individuals with discounts for prompt payment, bundled care, or memberships. If you have out-of-network coverage, then you can submit a receipt to your insurance plan for payment. You can get receipt (or superbill) from your doctor. Websites like Reimbursify helps with submitting your bill to your insurance company.
Neurotest of New York accepts most major insurance plans. However, with the complexities of sub plans we advised you to contact your insurance carrier for the most accurate answers and determination of in-network coverage. At Neurotest of New York, we try to estimate a patient’s responsibility for the visit and services to be paid at the time of your visit in order to avoid a surprise bill later. For example, you go to a mechanic to fix your car and get an estimate that you pay before the mechanic begins working on your car.
Hopefully, this article has taken some of the mysteries out of the medical insurance coverage process. I hope that understanding your health insurance plan will allow you to be empowered and advocate for your health as you work with our neurologists.