Understanding Your Health Insurance

By Ann Dennison

This week I’d like to discuss health insurance – what you should know about your policy, your responsibilities under the policy, and what your health care providers responsibilities are for your type of insurance.

There are 3 basic types of commercial insurance plans that may be provided by an employer or you may purchase as an individual.  The first is fee-for-service which is typically the most expensive and offers the greatest flexibility in providers. Next is health maintenance organization or HMO.  HMOs typically cover preventative services with lower co-payments, but your choice of providers is limited to those that are in the HMO’s network.  Otherwise, you pay higher fees when going with an out of network provider or facility.  The third type of insurance is a preferred provider organization or PPO.  A PPO also has lower co-payments, but typically has more providers from which to choose.

When deciding on insurance, if you have a choice of several plans, you should look at:

  • What right you have to choose your provider under the policy?  Will you have to change your primary care provider, physical therapist, optometrist, etc?
  • Is any specialty care (eye doctor, dentist) covered?
  • Is maternity care covered?
  • Is rehabilitation covered? Are there limits to the amount covered?
  • Are medical devices covered such as braces or artificial limbs?
  • Is medication covered and are there restrictions on where you  may purchase your medications?  Are there different tiers of medications requiring different levels of out of pocket expenses?
  • Is there a deductible?
  • Is there a co-pay or co-insurance?
  • Is there an out of pocket maximum?
  • What is the appeal process for denied claims?

The Affordable Care Act requires health insurance companies to prepare a Summary of Benefits and Coverage in a standardized format so that you have a more easily understood and consistent way to compare health plans when making decisions about your health care insurance coverage.

In our office, the most poorly understood terms are co-pay and co-insurance.  A co-pay is a specified dollar amount that the covered individual must pay per visit for services rendered.  The co-pay may be different for different types of providers. In recent years, the dollar amount of co-pays has been rising and several states have actually capped the co-pay amounts that insurance companies are allowed to require.  Co-insurance is a percentage of the amount  the insurance company allows for each visit that the individual is responsible for paying and is often collected following payment to the provider from the insurance company.  The amount of the co-insurance could vary from visit to visit depending on the care provided.  When the provider is participating, the contract between the provider and the insurance company states that the co-pay or co-insurance must be collected for each visit.  The provider may not arbitrarily waive these or the provider is in violation of his/her contract with the insurance company. For some plans, the co-pay and co-insurance apply only until the deductible is met, for others they may apply until an out of pocket maximum is met and for still others, they may always apply.

Kristen Pagano Advanced Physical Therapy and FitnessMost health care providers have billing specialists that can help you understand your benefits.  Healthcare providers can usually access your coverage information via your insurance company’s website.  However, it is always a good idea to understand your coverage and access the information on your own, too.  In some instances, the websites do not indicate if/when co-pays or co-insurance no longer need to be collected and in instances where you are visiting more than one provider, the information about deductibles being met, may not be up to date.  If you receive an Explanation of Benefits from you insurance company and have difficulty understanding it, ask your provider’s billing specialist to assist you, or call the insurance company and ask for an explanation.

Just because your plan states that you are allowed 20 physical therapy visits per plan year, does not mean that the insurance company will pay for that many visits for a specific condition.  Many insurance companies are using some type of utilization management tool whereby your provider must request visits by providing documentation of your function and impairments.  Visits will be approved, denied or decreased from what the provider requested.  Each insurer using this type of resource management uses a different system to make their determination.  Denials may be appealed in many instances, so it is important to know your appeal rights and the way to file an appeal for your specific insurance. This information can be obtained from your health insurance company.

The health insurance rules and regulations have been changing quite a bit in recent years, and probably will continue to do so.  It is important for you to understand your insurance coverage and responsibility for payment.  Be sure to get a Summary of Benefits and Coverage from your insurance company. When in doubt, ask.

If you have any questions on this topic or any others in which you are interested, feel free toleave any questions, comments, or suggestions.  Thank you for reading and stay active.





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