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Navigating Coverage, Bills and Networks

Navigating Coverage, Bills and Networks

Many of our patients are fortunate to have some form of health insurance. The Affordable Care Act opened the door for many to get health insurance that they previously couldn’t access. Whether you have a marketplace plan through the Affordable Care Act, a private insurance plan or even Medicare, your plan may require that you share the costs of the health care services you receive. Often we are asked questions about insurance coverage. We know it’s a complicated subject that keeps us all on our toes. And, of course it changes every year for most of us. We recently sat down with Generations insurance specialist Shenik R. Pinder, CPC, CPCO, MA to discuss some of the questions she frequently hears from patients.

Why do I have a bill?

The simple answer is that when health insurance only covers part of the cost of a medical procedure or service, the portion not covered by insurance is the patient’s responsibility. The much longer answer involves discussing copayments, deductibles and coinsurance.

Regardless of the type of health insurance you have, coverage levels vary from plan to plan even within the same health insurance company. Coverage amounts are determined and set by the entity that is paying for the plan, such as an employer who is offering a private health insurance plan as a benefit to its employees.

In most situations, a patient will have to pay a copayment at the time of service. This could be $15, $25 or even up to $100, depending on the plan. In addition to the copay amount, a patient might have a plan with a deductible. A deductible is the amount you are responsible for paying before the health plan begins to pay. For example if the deductible for your specific plan is $1,000, your plan won’t pay for any care until you have paid $1,000 out-of-pocket for covered health care services. Even after your deductible is met, the plan may not cover health care costs completely. Your plan might also require co-insurance, which means the plan covers up to a certain percentage of the cost and the patient is responsible for the rest. Many plans cover up to 80% leaving the patient responsible for the remaining 20%. Some cover up to 70% leaving patients responsible for the remaining 30%. It all depends on how the employer set up the boundaries of the health plan. Another variable that affects coverage amounts is whether the provider is “in network”. Each plan has a list of approved providers it considers “in network”. These are the providers that agree to the plan’s level of reimbursement for services often solidified in an annual contract. If you receive care from a provider that is “out of network,” your plan will require you to pay a greater share of the cost. This is why you have a bill ~ because your health insurance plan is responsible for certain costs and you are responsible for the rest. We know it can be difficult understanding your financial responsibility so we’ll do our best to help you understand.

Why do I have a separate bill for lab tests?

The providers you see at Generations provide one type of service, a medical lab is a separate entity that provides another type of service. Your health plan may cover lab services at a different coverage level, and not all lab tests are covered. We recommend that you contact your health insurance company to determine which lab tests your plan will cover and how much they will cover. This will help prevent surprises when you open the mail and discover you have a separate bill from the lab company.

Do you take my insurance?

We work with many insurance companies. However, not all insurance companies work with all providers. Even within a large health insurance company, there can be a different health plans within the company that only covers care provided by a specific set of providers. Please check with your insurance company to make sure your provider is in network.

Why are preventive services not 100% covered?

Again, this depends on your health plan. Under the Affordable Care Act, marketplace plans are required to cover certain preventive care at 100% without copays or coinsurance, making it free for you. But Medicare for example has different policies for covering preventive care. Likewise, private health plans cover different preventive care services at different coverage levels.

Whenever you have questions we recommend that you contact your health insurance company to find out the answers. We are happy to assist you as well.

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