What Ails You: Make sure you understand your health coverage

Let’s talk a little about health insurance. Even if you don’t get to choose your health plan yourself (your employer or union may have already made that choice for you), you still need to understand what kind of protection you have and how to use that plan to get the care you need.

No plan will pay for all the costs associated with your medical care, although some will cover more than others.  Most folks are covered by preferred provider organizations (PPOs) or health maintenance organizations (HMOs).  Very few folks have point of service plans (POS) which allow them to go to any provider anywhere. Medicare is one of these; you go to the doctor of your choice unless you have signed up with one of the Medicare alternatives like Secure Horizons or Medicare Advantage.

A PPO will generally offer a greater choice of doctors, hospitals and other health care providers than HMOs while requiring you to pay a greater percentage of the cost of that care. You will have a deductible each year and will be responsible for a given portion of your medical expenses (usually 20-40 percent). You help to control insurance cost by choosing a provider that is within the PPO network. These providers have agreed to provide services at a reduced rate. Your insurance policy may allow you to go out-of-network, but because the insurance company has lost their bargaining power with this non-network provider, the higher cost of the care is passed on to you.  Instead of your usual 20 percent, you will pay more to an out-of-network provider.

Under a PPO, you will be responsible for a deductible. This means that you agree to pay the first medical expenses up to a given amount. Normally, the deductible is broken down into a “per member” versus “per family” maximum. You may need to pay $250 per family member, but no more than $500 for the family so if two family members have met their deductible, the remaining members have no deductible for the remainder of the year.  Still, after the deductible, you may be responsible for paying some percentage (normally 20 percent) of the remaining bill.

With an HMO, payment has been made in advance to your primary care doctor and hospital. In general, you will have lower out-of-pocket expenses with an HMO, but you will have a narrower selection of doctors, hospitals and other providers than if you had a PPO. Further, any care you need over and above that provided directly by your primary care physician must go through an authorization process that may be time-consuming and limiting.

Some folks faced with high deductibles and co-insurance payments turn to the medical provider for help. It is not unusual for folks to ask if I would be willing to write off their deductible for them along with any additional payment they would be responsible for. Consider what you’re asking. If I see you eight times and my average bill is $60, my bill will be $480. You have a $250 deductible which you’d like me to write off so now my bill is reduced to $230. Your insurance company says you pay 20 percent so now you want me to write off $46. You’re asking me to provide your care for $184 or about $23 per visit. In return, my bill counted toward your deductible and your family maximum of out-of-pocket expenses. I can’t pay my bills if you insist that I pay yours. I will, however, agree to an affordable payment schedule so your expenses present as little hardship to your family as possible.

It is your responsibility, before you go see a health professional, to understand your insurance provisions, but it can be baffling. Don’t be afraid to ask for help. Talk to your human resources representative, a representative for your insurance company or the office manager where you are receiving care.

ABOUT THE WRITER:
Jackie Randa is a physical therapist who owns Back on Track in Barstow. She can be contacted at jranda@aol.com