Insurance Information

/Insurance Information
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Gone are the days where most people have a simple copay to see a doctor and the rest is covered. The new normal is high deductibles and restricted plans, meaning more patient expense and less insurance coverage. How much do you know about your plan?

Let’s start by learning some insurance basics…

The Different Types of Insurance Plans:

  • HMO – A Health Maintenance Organization that provides health insurance coverage to its members through a network of participating providers, hospitals, and other healthcare providers. (May require a referral).
  • POS – A Point of Service carrier that provides health insurance coverage and allows its members to go out of its network of providers and hospitals, but requires its members to pay higher out-of-pocket costs. (Referrals and prior authorizations may apply).
  • PPO – A Preferred Provider Organization that provides health insurance coverage using a group of providers, hospitals, and other healthcare providers who contract with the carrier to provide services to its members at a discounted/contracted rate. The PPO also provides health insurance coverage for services that are rendered by out-of-network providers at a higher out-of-pocket cost to the member. (No referrals necessary).
  • EPO – An Exclusive Provider Organization that provides health insurance coverage using a group of providers, hospitals, and other healthcare providers but does not cover any out-of-network services. (No referrals necessary).
  • MSP – Medicare Secondary Payor is when Medicare is the secondary payor because the beneficiary has coverage through a group health plan, worker’s compensation, or there is other third party liability.
    Medicare Advantage Plan: Is another Medicare health plan choice offered by private companies approved by Medicare. The Medicare Advantage Plan will provide Part A and Part B coverage, and may offer additional coverage such as vision, hearing, dental, and prescription drug coverage.
  • PFFS – A Private Fee-For-Service plan is a Medicare Advantage (MA) health plan that provides beneficiaries with all their Medicare benefits plus any additional benefits the company decides to provide. Beneficiaries can see any provider who is eligible to receive payment from Medicare and agrees to accept payment from the PFFS MAO.
  • HSA – A Health Savings Account in which yearly limited maximum contributions are made into the account by the member or their employer. The HSA is used for medical expenses not covered by the member’s health plan or in which the member has a high deductible.
  • HRA – A Health Reimbursement Account is an employer funded plan that will reimburse employees for health care expenses not covered by the employer’s health insurance plan.
  • COBRA – Consolidated Omnibus Budget Reconciliation Act is a federal regulation that allows employees and certain dependents to continue their group health insurance coverage for a set period of time when coverage is lost following a qualified event (job termination, reduced work hours.

Understanding Insurance Verbiage:

Determination/Verification of Benefits – Means we have verified and confirmed with the carrier specific benefits that are available based on the patient’s health benefit plan. Determination of benefits is not a guarantee of payment.

Pre-Certification – Means we can perform a specific procedure, but it is not a guarantee of payment.
Prior Authorization: Means your service will be paid. Prior authorization from the carrier has to be obtained and provided in writing. Prior Authorization is a guarantee for payment.

What is a PCP – A PCP is a family physician, family practitioner or general practitioner that is responsible for delivering or coordinating care.

Participating Provider – A healthcare provider who has a written agreement (contract) with an insurance carrier to provide covered services to its members.

Individual Deductible – The amount of money the patient is responsible to pay out of pocket before insurance company will start to pay. The deductible is usually paid once per calendar year (Jan-Dec).

Family Deductible – Under this arrangement, if the designated number (2-3) of the family members meet the deductible in full then the deductible is deemed satisfied for all family members.

Annual Out of Pocket (OOP) – This is a set dollar amount that the insured must pay for all medical costs before an insurance plan pays 100% of the bill.

Copay – The fixed dollar amount that a patient is required to pay as their share of the cost of certain services each time they receive care from a participating provider.

Coinsurance – Cost-sharing requirement that the insured pay a designated percentage of the allowed amount for covered services.

Carry Over Deductible – If an insured should meet their deductible in the last three months of the year, it will carry over (rollover) to the following year. (It is very rare that carriers provide this benefit).

Maximum Lifetime Coverage – The maximum benefit amount that a carrier will pay out in an insured’s lifetime. Once the maximum benefit amount has been reached, there is no longer any coverage available under that policy.

Pre-Existing Condition Clause – Is a pre-existing condition that was in effect six months prior to the effective date of the policy. It can only be excluded for one year after the effective date of the policy.

Exclusion – An item, service, procedure or diagnosis not covered by the carrier.

Covered In-Network – What % of the services is covered if the provider is in-network?

Covered Out-of-Network – What % of the services is covered if the provider is out-of-network?

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