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Understanding Medical Insurance
Medical insurance can be very confusing and understanding your policy can be frustrating. Insurance policies are usually very long documents which contain a lot of difficult terminology, and what is covered can differ significantly between plans. The purpose of this discussion is to help you better understand the terms associated with your insurance policy and it is not intended to describe anyone’s individual plan. It is best to call your insurance company if you have questions about the specifics of your policy.
To begin with, it is important to understand that the original purpose behind medical insurance was to provide coverage for a serious illness or injury that required hospitalization. Most routine or preventative care was not covered under these policies. An analogy is how auto insurance is used: it pays for repairs and injuries if you are involved in an accident but does not cover the cost of tires, routine repairs, oil changes, gas, etc. Over the past 50 years there has been a shift in the health insurance industry, because preventative care is helpful in avoiding serious illnesses. However, in recent years, there has been a push back to no longer cover preventative care. It is important to remember that insurance is one of the biggest for-profit business industries in the world and the decisions made in the boardroom are about dollars and cents, not how to provide the best healthcare for you the patient.
Understanding the terminology of insurance policies will better help you to know what your particular plan does and does not cover, helping to avoid surprises. The following is a list of terms you may find within the policy and what they mean.
Premium: this is the monthly payment you make to the insurance company to pay for your policy. The amount can vary a lot. If you get insurance through your employer and have benefits, some of the premium cost is paid by the employer and the rest is paid by you. The amount of insurance premiums has increased substantially in the past 3 years.
Co-Pay: A payment made by the patient during a visit at the doctor’s office, emergency room, e-care or imaging center. This payment is your portion of the overall cost of that particular day’s visit and does not include the portion that is billed to the insurance. The amount of your co-pay will depend on your policy and usually ranges anywhere from $0 to $100. Your insurance card typically has this information printed on it but it can also be found in your policy paperwork. Your co-pay can also be different depending on the type of doctor you see. For example, your co-pay to see your primary care doctor may be $25 but the co-pay to see a specialist may be $50 and it could be $100 if you went to the emergency room.
Co-Insurance: this term is often mistaken for co-pay however, it is very different. Co-insurance is the amount that you are responsible for paying during a visit or when having a procedure and is generally 10-30% of the total cost, where the insurance pays the remainder (70-90%). Co-insurance is usually required after you have met your deductible (see below for a description of deductible). Some policies have no co-insurance after meeting the deductible, meaning that the insurance company pays 100% of all remaining costs after the deductible is met.
Deductible: this term refers to the amount of money an individual (or family) must pay before the insurance begins paying for medical services. The deductible can range from $100 to $20,000+. The deductible amount differs depending on your policy and is tied to the cost of your monthly premium (the higher the premium, the lower the deductible usually). Typically there is an individual deductible for each person on the policy and a family (or group) deductible that is higher but is less than the total of all individual deductibles combined. This is not to be confused with individual or group out of pocket expense which will be explained below. The amount of deductibles in plans has increased dramatically in the past 3 years even though premiums have also increased substantially.
Individual (or family) Out of Pocket: this term refers to the total amount of money the patient (or family) must pay during the term of the policy (1 year usually) for medical expenses. Not every policy includes an individual or group out of pocket maximum.
Referral: this term refers to a letter that is required to be written by your primary care doctor in order for you to see a specialist. Referrals are typically required in HMO plans (see description below).
HMO/PPO: HMO stands for Health Maintenance Organization and these plans were designed to put preventative care at the center of the health plan. These usually include low co-pay plans that are intended to promote seeing your primary care physician routinely to help prevent health issues. These plans have become higher deductible plan plans in recent years, making preventative care costs lower but increasing the costs when an illness or injury arises. HMO plans typically require referrals from your primary care doctor to see a specialist.
PPO stands for Preferred Provider Organization. These plans were designed to create a network of providers that the insurance company prefers and includes primary care physicians and specialists of all kinds. Referrals are typically not required with these plans and the patient may see specialists when needed. Co-pays and deductibles vary widely with these plans and, as with all insurance policies, the amount of your premium determines these amounts.
HRA/HSA: HRA stands for Health Reimbursement Account. This account is set up by an employer to reimburse an employee for health costs that are not covered under their plan. This money is tax deductible to the employer. The amount in the HRA varies by employer and is reset every year. If there is any remaining balance it usually does not carry over to the next year.
HSA stands for Health Savings Account. The money in this account is put in by the policy holder and is tax exempt. It is used for those who have a high deductible plan where they have a lot of out of pocket expenses. The money that goes into this account can be deducted from your paycheck prior to taxes being withdrawn.
This discussion of health insurance is intended to be a simplified guide to the terms used in your policy and in no way is an explanation of your individual plan. It is up to you to understand what your plan does and does not cover. If you have questions regarding your plan it is recommended that you call your insurance company for clarification.
The doctors and staff at Advanced Foot and Ankle Center have extensive experience with insurance and are committed to providing you the highest quality foot and ankle care available. Call for an appointment today to speak with our qualified staff!