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by Molly Lipke, MD, Practice Manager for Ten Mile Family Medicine

It is extremely difficult for health care consumers (patients) to navigate through the confusing and frustrating world of medical insurance. Most insurance plans change frequently, often with shrinking benefits and growing co-pays and deductibles.

In order to be a SMART healthcare consumer, you must know what types of services are covered by your insurance plan, which providers are covered or in-network, how to find answers to questions like these, and how to contact your health insurance company to appeal or dispute a decision on coverage. Most clinics and hospitals can answer some basics questions about common health insurance plans, but there are hundreds of insurance plans out there and it is the primary responsibility of the health care consumer (patient) to know the details of his or her medical insurance plan and benefits.

For example, you should know…

• What is a co-pay and do I have one?

A co-pay is a set fee that is charged each time a person visits a health-care provider (anywhere from $2 to $50 depending on the plan). Some insurances charge a co-pay for lab and nursing visits as well, but most only charge the co-pay for a provider visit.

• What is co-insurance and do I have one?

Co-insurance is a set percentage of a bill charged to the patient for various different types of health care costs. Some insurances charge a co-insurance on labs, provider visits, procedures (such as electrocardiogram, incision and drainage, etc.) or a combination of these.

• What is a deductible and do I have one?

A deductible is a set amount of money per year that the healthcare consumer has to pay out-of-pocket before insurance benefits kick in. Often, deductibles for individuals and families are different. It is crucial for consumers to know when the deductible year starts for their plan, so elective medical costs can be spent toward the end of the deductible year if the deductible has already been met, or at the beginning of a deductible year if it has not been met.

• What services are not covered by my health insurance plan?

Some insurance plans do not cover mental health services, pre-existing conditions (at least for some period of time after starting on a new insurance plan), pre-natal/maternity care, birth-control or sterilization procedures, medical equipment, etc.

• Do I receive a “free” annual health maintenance exam under my plan, and when am I due for that?

Most insurances provide an annual health maintenance or wellness exam for free, not subject to any deductible or co-insurance and often not even subject to a co-pay. Make sure to let your healthcare provider know that you are scheduling and expecting your annual wellness exam, so it can be performed and coded as such in order to receive this annual benefit.

• Do my children receive annual well-child examinations for free, and when are they due for this?

Most insurances provide these regular health maintenance visits (including immunizations) for free. Call your insurance company or read your plan to figure out the periodicity of these free exams and when your child is next due for this.

• Does my insurance restrict which providers I may see? Does my plan fall under a PPO (preferred provider organization) and if so, who is in-network for this?

Most insurances have this information available online, or you can call your insurance to verify that a certain provider or facility is covered by your plan.

• For Medicare patients with supplemental insurance, does my supplemental insurance pay my annual Medicare deductible and all co-insurance for visits, or only part of these costs?

• For Medicare patients with a Medicare Advantage plan, are there certain providers and facilities that are in or out of network for me?

• For Medicare patients, make sure you schedule your free Welcome to Medicare physical, and annual Medicare wellness exams after that. These types of exams are completely covered by Medicare and do not apply to the annual Medicare deductible or any co-insurance.

• For patients without health insurance, talk to your provider/clinic/facility about any discounts that can be given for those without insurance. Often these discounts for the uninsured are significant, but may require payment at the time of service. Also, contact Social Services to inquire about any potential assitance that may be available.

Being armed with a full understanding of your medical insurance benefits can help you plan ahead for your portion of medical bills and can also help you identify errors in the medical billing process. Please read the details of your insurance plan or call the number on the back of your insurance card to clarify any questions you may have about your plan.

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