Health Insurance 101

Health Insurance can be very confusing, when selecting a
plan it is important to know what is going to be your responsibility, your employer’s responsibility, and lastly your Insurance Company’s responsibility.

Health Insurance has changed over the past 30 years and it is no longer a card that you can show and expect for your entire Healthcare bill to be paid for, it is important to understand what parts you are going to be responsible for and what your insurance company will cover.

In Today’s Health Insurance World, there are three parts of the
Health plans where you are going to have to pay out of your pocket for your
Health coverage.

Part 1 is the Monthly Cost. This is the part that comes out of your paycheck. Many times your employer covers part of this cost. The Monthly Payment can vary in expense depending on if you are covering just yourself, or Husband/Wife, or your entire family.

Part 2 is the Co-Pay associated with your plan, this is the amount of money that is owed up front when you go to the Doctor's Office. Part 3 is the deductible associated with your plan. This is the amount of money you must pay first, before your Health Insurance will pay for any of your Healthcare (Excluding annual well visits sometimes called physicals).

Think of your monthly payment in the same way you would think about your BJ’s/Costco/Sam’s Club Card, your monthly payment gets you a discount on services rendered at the doctor's office. Ensure your doctor’s office will accept your plan in-network, you will then get the discounts applied to your bill. You can always call ahead and ask the front desk staff if your insurance is accepted there.

Doctors can bill however much they want for the services they render, but the health insurance company determines how much you will owe.

Doctors Express in Pikesville accepts Blue Cross/Blue Shield, Cigna, Aetna, Medicare, Medicaid, to name a few insurance plans. It's open seven days a week, and is located at 1860 Reisterstown Rd., Ste. A. If you have any questions please give us a call at 410-484-4044.

For example, if you have CareFirst Blue Cross/Blue Shield and present your card to a doctor's office that is in network with BCBS, the doctor might
bill $400 for your visit, but the doctor has a contract with Blue Cross that
says the member (you the patient) only will owe $125. You will see this amount deducted from your bill, and it will say “Discount” on your EOB (Explanation of Benefits), in this case the discount is $275. You have gotten this discount because you pay your monthly premiums to Blue Cross, and this $275 is the benefit of being a Blue Cross Blue Shield Member.

The doctor has yet to be paid anything by the insurance company and you may or may not owe this amount depending on your co-pay and deductible.  If you were not a Blue Cross Blue Shield member, you would be responsible for the entire $400.

Generally, a lower monthly payment will lead to a plan with higher co-pays and deductibles. So if you go to the doctor regularly for a medical condition, you may want to pay a little more up front so that you save money in the long run.

Your co-pay is a down payment for your Healthcare, Health Insurance Companies use Copays to ensure that medical services aren’t being
over utilized or abused. By having a co-pay, the insurance companies believe that medical services will only be sought out when they are truly needed. Think of your co-pay the same way you think of a down payment on a car or house, they cannot be discounted by doctor's offices, and they must be paid up front at time of visit.

In the example we used above, let’s say you had a $20 copay and you paid that at your time of visit. That $20 would be deducted from the total amount owed of $125, so your total outstanding bill would be $105. ($125-$20=$105). If you have a medical condition and you
know that you will need to see a specialist regularly, select a health plan
that may have a lower copPay, this can help save money over time.

Lastly, the most-feared word in health insurance: deductible.

A deductible in health insurance is the same as a deductible on your car
insurance. When you get in an accident and you file a claim to have your car
fixed, most auto insurance companies make you pay the first $500, then the auto insurance will pay the rest. The same is true with your health care. Most plans these days carry a $500 to $1500 deductible. Meaning, you must pay for the first $500-$1500 worth of healthcare you receive in a given year. Where people get confused is the difference between their annual well visit/physical and a sick visit. Most health plans will include 1 or 2 annual Well Checkups for the year as part of your membership benefit.

However, if you do not have a well visit, or you get sick before your first well visit, that sick visit cannot be counted towards your 1 or 2 checkups.

The health insurance companies have figured this out, there are more than 20,000 codes for various healthcare visit reasons, and in
order for your visit to be free or counted as a well care visit, you cannot
have a code on there for a sick examination or any sort of testing (i.e. strep
throat etc.).

The days of health plans with $0 deductibles are very rare. They usually only come with Medicaid (state-paid insurance) or if your employer pays for your deductible. Expect on your first 1 or 2 visits to the doctor's office every year to pay for that visit out-of-pocket. You can always call ahead to your insurance company to figure out how much you will owe. If you have a medical condition, and are going to need ongoing medical treatment, a plan that has a higher monthly payment, but a lower deductible, again could save you a lot of money over time.

Keep in mind, that if you do have a deductible, you haven’t met your deductible yet, and you are billed for your deductible, your doctor has not been paid one penny for your visit.

Expect your doctor's office to aggressively pursue this payment. In our example above, if you have yet to meet your deductible, you would owe the remaining $105. If you cannot pay that all at once, always contact your doctor's office and let them know.

They may be willing to setup a payment plan. However, if you have met your deductible (meaning you paid out of your own pocket $500-$1500 this year) your health insurance will pay the doctor $105.

A couple tips on how to save money in Healthcare.

1. Properly Utilize Urgent Care vs. the Emergency
   Room. Insurance companies set most Urgent Care’s copays at $20-30, while the Emergency Room typically has a co-pay of $75-150. The Emergency Room should only be used for life
   threatening emergencies. Doctors Express in Pikesville can see you for anything else.
2. Look at how many times you went to the doctor last year. If you hardly went at all, then the chances of a health plan with a
   lower monthly payment, but a higher co-pay and deductible will work best for you. However, if you went to the doctor twice a month, paying a little more up front could save you $1,000 over the year.
3. Set up a Health Savings Account, this money can
   be deposited into your bank account pre-tax and can be used for anything Medically related. Everything from doctor's visits to cold medicine.