The Affordable Care Act is less than a year old but already we have seen changes and an increase in confusion about how insurance works. We regularly field phone calls from (justifiably) frustrated patients who are unclear about their insurance plan. Believe us, we feel your pain.
Insurance is complicated, and is likely to stay that way. The best way to combat this challenge is to educate yourself. With that in mind we have compiled a list of some of our most frequently asked questions and our most helpful answers.
What is a Co-Pay?
A copay is a fixed amount you pay for a health care service, usually when you receive the service. The amount can vary by the type of service. You may also have a copay when you get a prescription filled.
For example, a doctor’s office visit might have a copay of $30. The copay for an emergency room visit will usually cost more, such as $150. However, there is a maximum amount you will pay for coinsurance and copays. This is called the coinsurance and copay maximum.
What is Co-Insurance?
Having a health plan that requires you to pay a coinsurance, or percentage participation rate means that you split the cost of your healthcare with your insurance carrier.
For instance, if your health plan has an 80/20 co-insurance rate, (coinsurance rates of 70/30 90/10, and flat rates of $5.00 to $20.00 per doctor’s office visit are also common) your insurance plan pays for 80% of your eligible medical expenses and you’re responsible for the remaining 20%.
What is a Deductible?
In an insurance policy the deductible is the amount of expenses that must be paid out of pocket before an insurer will pay any expenses. In general usage, the term deductible may be used to describe one of several types of clauses that are used by insurance companies as a threshold for policy payments.
What Does Out of Network Mean?
An “out of network “medical provider will not receive payment for services if not pre-authorized by a medical insurance company. This means the patient may be responsible for the entire balance.
The final thing we want to stress to you is that while we may hold a contract with your insurance company, your specific coverage plan is dictated by your contract with them; likely through your employer. Insurance companies determine how much of health care costs you need to pay and which providers are in network. Sound Family Medicine works with most insurance carriers, but we are not contracted with all carriers. The best thing you can do to ensure coverage is to contact your insurance company prior to obtaining services. It will help you understand what to expect with any health care visit you may need.
Due to changes brought on by the Affordable Healthcare Act and the Washington Healthcare Exchange, we have made updates to our insurance page. This page includes information regarding our non-participation in the Premera Exchange products and includes links to the insurance carriers we work with and a link to submit a question about your insurance. We encourage you to contact your insurer first, but if your question remains unresolved, please reach out to us. During the coming months we will continue to send out information about insurance to help you better understand the system.