Insurance

Your health insurance policy is likely set up so that you pay for some of the care out of your pocket and the insurance company pays part as well. A co-pay is a fixed dollar amount that you pay per visit. After you pay that amount the insurance will cover a percentage of your care. Most insurance companies will cover 100% of your care after you pay a co-pay of something from $5-45. This is nice because your out-of-pocket costs become very predictable. Co-insurance is when you split a percentage of the total cost of the visit with the insurance company. For example you may pay 30% of the treatment cost while your insurance company covers the other 70%. Most insurance contracts require that co-pays or co-insurance are paid when you go in to receive care.

You will typically pay a lower co-pay or co-insurance if you go to a Preferred Provider or somebody who is “In Network” with your insurance company. This basically means that the doctor has a contract with the insurance company that usually will give the insurance carrier a discount on services provided to people with their insurance plans. The amount a doctor will need to write off varies from insurance company to insurance company. Your insurance may provide “Out of Network” coverage but you may end up paying a higher co-pay or co-insurance.

Your deductible is the amount you need to pay for health services before the insurance will start to pay anything. Some policies don’t have deductibles.  Some are small like $200-500. Others are large like $1,000+. Your deductible will reset each year.  Some plans reset on the calendar year meaning that in January you will have to start over and pay your deductible again. Other plans will reset one year from when the plan started (June to June for example). Most insurance contracts between the company and the doctor prevent the doctor from waiving any deductible fees.

HSA stands for Health Savings Account and FSA is a Flexible Spending Account. They work very similarly. You or your employer can put money into this account to use only for health care expenses. This is nice when you have a high deductible plan because then there is money set aside to help satisfy the deductible each plan year. Also it gives you flexibility to choose what kind of health services you want. This way you aren’t just confined to prescription drugs and surgery at the hospital of the insurance company’s choice. Often the administrator of the account will provide you with a benefits card which will work like a debit card.

Whenever your insurance receives a bill from the doctor’s office they make a decision as to how much they will pay. They send payment and an “Explanation of Benefits” (EOB) to the doctor with the payment. They will usually send or e-mail a copy to the patient as well. This details how much was charged for each service provided (exam, adjustment, etc), how much the patient owes (co-pay, co-insurance, uncovered services, or deductible), how much the doctor writes off based on their contract and how much the insurance company will pay. If they do not pay there is an explanation why they won’t.