Understanding Your Insurance Benefits
It’s amazing how many patients don’t understand their health insurance coverage even though it is one of the most important investments we will ever make. Having health coverage is important to ensure we aren’t stuck with covering emergency medical costs or even just an office visit for an illness. There are many different parts to health insurance, and to be honest it is exhausting to understand all the different health insurance plans. However, I will do my best to explain health insurance in the simplest way.
picture this- you pay your insurance premium monthly to ensure you are covered. Your agent sits down with you and explains your benefits to you, let’s say you have a deductible of $2,500, coinsurance of 20%, and an out-of- pocket of $4,500. However, you’re so distracted with life that you shut out their explanation. A couple months later you’re driving down the freeway and get into an accident, which sends you to the ER.
Yes!! You have health insurance, but how does it work from here.
- You will pay 100% of medical costs until your deductible of $2,500 has been fully met.
- your deductible is met; your health insurance will then pay 80% of your costs
- You’ll pay at 20% until your out-of-pocket is met
- Once your Out- of- Pocket is met your insurance will cover you at 100%.
Alert: Keep in mind all health insurance plans are different, and to make matters more confusing all coverage at medical office’s may also be different due to in-network & out-of-network providers
Let’s say after your accident you realize you had to pay too much, and would like to change your policy. You can either wait until your policy is close to expiring, or to change anytime you must experience a qualifying life event. This would include a marriage, divorce, birth of child, changes to income, or relocation.
You have a child and decide to change your policy to a copay and out-of-pocket policy. Your agent then describes your benefits to you over the phone, and you believe you have them down $25 copay and an out-of-pocket of $2,000.
but fully understanding them is another hurdle.
- You’ll pay your $25 copay due at the time of service
- Continue to pay the copay until your $2,000 Out-Of-Pocket is fully met.
After the pregnancy and birth of your new child, you realize your back has been bothering you and you decide to see the local chiropractor. You’re there and feel prepared that you understand your coverage. Upon check out at your 5th visit the receptionist asks for your $25 Copay, and proceeds to tell you that you do not have anymore insurance visits. Wait what! (This is where I mentioned above insurance is very complicated)
Alert: It’s important to call and speak with a representative from your insurance company before going to any medical appointment to know your coverage and if your insurance will even pay on claims.
For example: When going to see a local doctor- it’s important to look up if they are either in or out- of- network with your policy. If they are out-of-network, you may not have any benefits with that specific doctor. This issue is not the fault of the provider or clinic, but just that there are so many different plans it takes awhile to get in-network with all of them. Here at Active Wellness we are participating providers with most major insurance companies, however, it is your responsibility to contact your insurance company for your in-network providers and what benefits you might have here in our office.
