Health Insurance and Stethescope

About Health Insurance

Navigating the complicated world of health insurance can be confusing for most of us. Here, we look at how health insurance works, what to expect, important terms to know, and what your health insurance will pay for.

While you might think health insurance will always cover all your medical expenses, there are many costs that health insurance doesn’t cover. In fact, many struggle to understand the terms of their health insurance policies, and they may be caught off guard by unexpected out-of-pocket expenses or limitations to their plan.

DIFFERENT TYPES OF HEALTH INSURANCE POLICIES

Health insurance policies help cover the cost of medical expenses — including routine care, surgeries, and prescriptions. When buying health insurance, you’ll notice there are several different types of health insurance policies. These policies specify which doctors you can see and what types of care they cover.

There are four different types of health insurance policies:

1. Exclusive Provider Organization (EPO)

An EPO plan only covers in-network care, except in the case of some emergencies. This means you can only see providers within their health insurance network — except for some emergency room visits — and if you see someone outside the network, the costs aren’t covered.

2. Health Maintenance Organization (HMO)

HMO plans cover in-network care within a specific geographic area. Out-of-network care may be limited or covered only in emergencies. If you need to see a specialist, your primary care physician (PCP) will need to provide a referral. For example, if you have a skin issue and need to see a dermatologist, you’ll need to see your PCP first to get a referral to have the costs of your visit covered.

3. Point-of-Service (POS)

POS plans have discounts for in-network care but may cover some types of out-of-network care. This means that if you do see a doctor who is out-of-network, the visit could be partially covered. Just as with HMOs, though, you’ll need a referral to see a specialist.

4. Preferred Provider Organization (PPO)

PPO plans have lower rates for in-network providers but more options for out-of-network care than other types of plans. This type of plan also doesn’t require a referral to see a specialist, so if you need to see one (like a urologist), you can just make an appointment without visiting your PCP first.

WHAT AFFECTS THE COST OF HEALTH INSURANCE?

Health insurance premiums vary based on your age, location, the type of plan you choose and your risk factors. Note that the Affordable Care Act and other regulations mandate that premiums for older adults max out at three times the premium costs for a 21-year-old.

For example, if an insurance company charges $200 per month for a plan for a 21-year-old, a plan for a 64-year-old will cost no more than around $600. Some states may even mandate that all plans cost the same, regardless of age. And those who are 65 years old and older can qualify for Medicare.

Generally, health insurance plans with a higher deductible will cost less than those with a smaller one, but that means they won’t pay for as many of your medical services during the year. For example, a plan with a $5,000 deductible will cost less than one with a $1,500 one, but if you have very high medical costs, you’ll pay much more out-of-pocket, which is more expensive long-term.

COMMON HEALTH INSURANCE TERMS

Some of the terms you will run into when dealing with health insurance can be confusing. Here is a breakdown of some of the most common ones:

  • Waiting period: The period before your health insurance kicks in after you sign up for a policy.
  • Pre-existing condition: A health issue, such as cancer or diabetes, that exists prior to enrolling in a health insurance plan. Plans cannot refuse coverage — or charge you more for these conditions — according to the Affordable Care Act.
  • Health insurance premium: The amount of money you pay each month or biweekly to maintain your health insurance coverage.
  • In-network provider: Insurance companies have agreements with certain doctors who agree to be paid the insurance company’s rates. These doctors are classified as being in your network.
  • Out-of-network provider: Doctors who do not agree to the health insurance company’s rates are “out-of-network.” Some policies have a separate deductible for out-of-network care, and some do not cover out-of-network providers at all.
  • Out-of-pocket expense: Medical expenses you must pay on your own that are not covered by insurance.
  • Preventive care: This type of care includes such things as annual checkups with your doctor or screening tests like colonoscopies and mammograms. Health insurance typically covers these expenses at 100% regardless of your deductible.
  • Prior authorization: The approval needed for your health insurance to cover medical procedures such as surgery or medications that aren’t usually covered.
  • Primary care physician (PCP): The health care practitioner who you designate as your primary point of contact for medical services. The PCP will also provide referrals to specialists.

HEALTH INSURANCE TIMELINES

When you sign up for health insurance, it won’t kick in right away. Your initial waiting period may last up to 30 days before your health insurance will be available for you to use. And some employers may even require that you work for up to one year before providing health insurance.

Once your policy is active, health insurance generally takes time to approve procedures and process claims. While you won’t need prior approval for things like doctor visits and emergency room care, if your doctor recommends a surgical procedure then your insurance will have to approve it before covering it. This process generally takes several days to a week.

Once approved, your insurance will cover your treatment. For procedures that are not approved, your doctor can submit an appeal, which will take a week or more to review.

Prior authorizations are also needed for things like prescriptions, especially those not normally covered by your insurance plan. If a prescription is not normally covered, your doctor will have to submit paperwork to show you have tried other medications that are covered and have not worked. The approval time is much the same as it is for surgical prior authorizations.

COST SHARING IN HEALTH INSURANCE

Insurance companies over the last few decades have increasingly used “cost-sharing” to encourage their customers to use healthcare services more carefully. This means consumers are responsible for a portion of the bills for their care. Even for those services covered under a health insurance policy, the consumer can be on the hook for significant out-of-pocket expenses. Costs associated with health insurance may include:

  • Premiums – The cost of the health insurance policy. It can be paid fully by the consumer, fully by the consumer’s employer, or shared between the two.
  • Deductible – The amount a consumer must spend before receiving any coverage under their policy, besides preventive care. For example, if the annual deductible is $1,000, the consumer must pay $1,000 in medical bills before their insurance company will pay anything toward health care bills, unless the care is covered by preventive care.
  • Coinsurance – The consumer’s share of a covered service (after meeting the deductible amount). This is usually a percentage of the cost of the service, often 20 percent. For example, if the consumer has met their deductible and they get a bill for healthcare for $500, the coinsurance is $100, and they must pay that. The insurer pays an additional $400. 
  • Copayments – Sometimes rather than paying coinsurance, a consumer must pay set amount of money for your healthcare expenses, including your doctor’s visits, emergency room visits and prescriptions. For example, if a policy requires a $20 copayment for doctor’s visits, the consumer’s out-of-pocket cost for the visit is $20, once they have met any applicable deductible. The insurance plan pays the remainder at a rate agreed upon with the provider. 
  • Out-of-Pocket Maximum – This is the maximum dollar amount of health care bills a consumer would need to pay in a calendar year. This figure includes deductibles, coinsurance, and copayments, but it does not include premiums. 

HOW HEALTH INSURANCE WORKS IN 3 STEPS

Health insurance policies help cover the cost of medical expenses — including routine care, surgeries, and prescriptions. Here’s how health insurance policies typically work:

  1. Each month you pay a fee called a health insurance premium. Premiums can vary based on your age, where you live, whether you use tobacco and the type of plan you choose. 
  2. Before your health insurance policy covers any of your care, however, you must meet your health insurance deductible for the year. For example, someone with a $2,000 deductible getting surgery will need to pay $2,000 of that expense before their health insurance will help pay for the rest. This number resets each year.
  3. Once you have met your deductible, when you go to the doctor for care, the health insurance policy may cover only a percentage of your bill, called coinsurance, or you may need to pay a flat fee toward your care, called a health insurance copay. The copay and coinsurance rates are predetermined amounts set by your health insurance company and agreed to by the doctor.

Many employers pay part of their employees’ health insurance costs. If your employer provides health insurance, your premiums are usually deducted from your paycheck.

If you don’t have employer-based health insurance, you can buy your own policy on the Health Insurance Marketplace, directly from commercial insurance companies or through an insurance broker. Keep in mind that you can only buy your insurance during open enrollment periods; Open enrollment typically happens between November 1 and December 15.

WHAT DOES HEALTH INSURANCE COVER?

Health insurance covers most medically necessary doctor visits, treatments, and procedures. Even before you meet your deductible for some covered services, your insurance will help save you money on them. These may include:

  • Doctor visits: While preventive visits for things like your annual check-ups are usually paid for in full by your insurance, other doctor visits may only be paid for after you meet your deductible for the year.
  • Vaccinations: Most childhood vaccinations and things like your annual flu shot or a COVID shot are paid for as preventive care.
  • Annual screenings: Your insurance will pay in full for tests like mammograms, colonoscopies, and cholesterol screenings as part of your preventive care.
  • Hospitalization: Your insurance will help pay for your hospital stay after you meet your deductible.
  • Emergency room visits: Most plans cover emergency room visits and emergency procedures like surgeries (in any hospital), but your deductible may apply.
  • Lab work: Your insurance will cover things like blood tests, urine tests and pap smear tests. For some tests, your deductible may apply.
  • Urgent care visits: Much like emergency room visits, your insurance will cover visits to urgent care, although you may need to visit an in-network facility.

Health insurance does not cover as much as it used to. Premiums, deductibles, copays, and coinsurance leave consumers with plenty to pay. 

Most health insurance plans leave a good amount of the cost of healthcare to consumers. Out-of-pocket expenses may include coinsurance, deductibles, and copays. Consumers also need to pay for services insurers may not cover or cover at a lesser amount, such as some infertility treatments, out-of-network doctors at network hospitals, nursing home care, and elective procedures.

Affordable Care Act (ACA) Required Services

Currently, the Affordable Care Act requires all insurers selling on the healthcare marketplace to cover certain services without limits on the amounts these services cost. The services, however, may still be subject to deductibles, coinsurance, or copayments. All health insurance policies must provide coverage for:

  • Ambulatory patient services (outpatient services)
  • Emergency services
  • Hospitalization
  • Maternity and newborn care
  • Mental health and substance use disorder services, including behavioral health treatment
  • Prescription drugs
  • Rehabilitative and habilitative services (those that help patients acquire, maintain, or improve skills necessary for daily functioning) and devices
  • Laboratory services
  • Preventive and wellness services and chronic disease management
  • Pediatric services, including oral and vision care

While the list seems comprehensive, there are still coverage limitations even within these mandatory categories. For instance, insurers may pay less for brand-name prescription drugs than for generics. Insurers will pay more for services at an in-network facility than at a facility not in-network. If in doubt, contact your insurer.

WHAT HEALTH INSURANCE WON’T COVER

Health insurance generally covers doctor visits, medical procedures, medical treatments, and prescriptions they deem medically necessary to maintain your health. However, there are some services most health insurance plans will not cover, even if the consumer has met the deductible and other out-of-pocket costs.

Long-term care, such as that provided in a nursing home, may not be covered by health insurance (including Medicare), unless it follows a covered hospital stay. 

Elective or unapproved medical care: Medical procedures and care that your doctor cannot provide medical necessity for, or that your insurance does not have prior authorization for.

Experimental or alternative treatments that the FDA has not approved will not be covered.

Some additional health expenses that may not be covered by insurers include:

  • Hearing aids
  • Infertility treatments, including in vitro fertilization
  • LASIK surgery to correct vision
  • Complementary medical treatments such as acupuncture, chiropractic, naturopathic and massage.
  • Weight loss programs and weight-loss surgery – Procedures such as gastric bypass surgery are generally not covered unless they are deemed medically necessary for your health.
  • Private nursing
  • Vaccines for travel
  • Cosmetic surgery: any surgical treatment that is not considered medically necessary for your health including things like liposuction, rhinoplasty, spider vein surgery and plastic surgery.
  • Doctors who are out of network, even if they perform services at an in-network facility.

DETERMINING IF YOUR DOCTOR AND MEDICATION ARE COVERED

When shopping for the right health insurance plan, it’s important to research whether the new plan will cover your current doctors and medications. The easiest way to find out? Call the insurance company to determine if the plan you’re interested in will cover your doctor, medication or even your preferred hospital.

Most insurance plans also have a provider directory you can search to determine whether your physician is an in-network provider. It’s important to note that if your doctor is not considered in-network, your health insurance generally won’t cover your visits or will cover a small portion of your visits.

For prescription coverage, most insurance plans also offer a searchable database of medications they cover. If your medication isn’t on this list, you can request that your doctor submits a prior authorization to get insurance to cover the medication.

FREQUENT Q&A

What insurance company does Eastwest Integrated Care accept?

We accept all major insurance -United Healthcare, BCBS, Aetna, Cigna, Tricare West, and Medicare. However, be aware that does not guarantee that our services will be covered. Your coverage depends on the PLAN you have acquired with the insurance company.

Where can I see the charges and payments from my insurance?

Your insurance company will send you an EOB (Explanation of Benefits) via mail or email, and some of them will make it available online on their patient portal. You will also receive a statement from our office; on that document you’ll see terms such as:

AdjustmentA contractual agreement that is made between your provider and your insurance company, reducing the charges to the “allowable” amount set forth in the provider contract with your specific insurance company.

Insurance BalanceThe amount corresponding to the claims pending with your insurance plan. Depending on your plan benefits, your insurance company may pay some or the entire amount. 

Patient Balance– The amount that your insurance plan has indicated is your responsibility to pay.

What if my insurance doesn’t pay?

If payment is denied by your insurance company, you are responsible for the outstanding balance on your account. It is your responsibility to know your insurance information and present the correct information to us upon check-in for your appointment. If you do not present us with the correct information, we will consider your account SELF-PAY. If your insurance has changed, please call us immediately with your new insurance information.

What types of payments options do EIC offer?

We accept cash, HSA/FSA cards, debit/credit cards including Mastercard, Visa, Discover and American Express among others. You can pay your bill through the patient portal, over the phone by calling our office at 520-308 5289 or in person during business hours – TUESDAY to SATURDAY from 10:00 am to 5:00 pm.

Why is Health Insurance Important?

Even if you’re healthy now, health insurance protects you if you become sick or injured later. You never know when a medical emergency might occur. If or when it does, you don’t want to owe the hospital or doctor thousands of dollars in fees. And delaying your care due to cost can lead to even more serious illnesses.

Health insurance can help you pay for preventive care as well. Your health insurance policy might cover vaccines, physicals, and blood work to help diagnose problems early or even avoid them altogether. This can help prevent costly medical conditions that may develop later.

Now that you know the basics of health insurance, you can make smart decisions about your medical treatment. If possible, find a health insurance plan that covers your medical needs at a cost you can manage. Make sure to fully understand the terms of your health insurance policy, so that you know what types of health insurance benefits it includes and excludes.

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